Date Format: MM slash DD slash YYYY
Do you have a spouse or other family member you would like us to add to the account who can make decisions about your pet's healthcare? Please use the field below to list any other pet owners and how they are related to you. All pet owners listed must be 18 years of age or older.
In the event of an emergency, it's important that we're able to get in touch with you as soon as possible. Please list any additional number you would like us to have on file and who we should ask for when we call.
Tell us how you found out about us.
If you selected 'friend', 'other', can you tell us the individual's name or the other source? We'd like to give them credit. Also, if you selected Google or Yahoo, can you tell us more about your search experience? After you saw our practice, did you read a review? Look at other practices? This information helps us improve the way our practice builds online content and reaches out to our clients
Tell us why your pet is here today.
Use this space below to tell us the breed of your pet or if you selected 'other' tell us what kind of a pet that you have.
If you do not know precisely, please approximate. At your visit, one of our veterinarians will help you determine your pet's age.
Date Format: MM slash DD slash YYYY
Does your pet have any medical conditions or history that we should know about? Please use the field below to list any major medical problems that your pet may have had in the past, any chronic health issues, or anything else that you think will be helpful for us to know when diagnosing or treating your pet.
Use the field below to tell us any medications that your pet is currently taking. List the medication name, the dose, and how frequently the medication is given.
Please use the field below to list the name and contact information (if you have it) of the last veterinarian that treated your pet. Can you also please tell us why you left their care?
Use the space below to tell us about any other pets you have at home. List the pet's name, what kind of an animal it is, and how old they are. Information on other pets in the household helps us better diagnose medical issues in our patients.
By typing or signing my name below, I acknowledge that I am at least 18 years of age and have the authority to authorize, and currently authorize the veterinarian to examine, prescribe for, and/or treat the above described primary pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospitalization.
By typing or signing my name below, I acknowledge that I am at least 18 years of age and have the authority to authorize, and currently authorize Brookfield Animal Hospital to photograph my pet for use on social media. Brookfield Animal Hospital social media posts are used to celebrate the human animal bond and to promote excellent veterinary care for companion animals.
Would you like to schedule an appointment for your pet now? Use the field below to provide the date and approximate time you would like your pet to be seen by one of our East Side veterinarians. Please include the reason for your visit. A representative from our office will be in touch with you within 24 hours.
By clicking the 'I agree' button below, you acknowledge that payment for East Side Veterinary services is due upon the time the service is rendered unless otherwise agreed upon by both parties. East Side accepts all major credit cards and cash, but not checks. You understand that interest and late fees will be applied to any outstanding balance on a monthly basis and that uncollected payments for services rendered will be turned over to a collections agency.
This field is for validation purposes and should be left unchanged.