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hello@wentzvilleanimalhospital.com
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New Client Form

Please fill out this form completely andbaccurately so we can get to know you and your pet(s) before your appointment.

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New Client Form

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us? *

Google
Facebook
Billboard
Personal Referral
Other

Who can we thank for the referral? *

If other, please specify *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings *

Sex *

Male
Neutered Male
Female
Spayed Female

What is your pet's current diet? *

Is your pet up-to-date on their vaccines? *

Yes
No

Is your pet currently taking any medications? *

Yes
No

If yes, please list the medication(s), including name, dosage, and frequency *

Has your pet had any previous illness or injury? *

Yes
No

If yes, please specify *

Is your pet allergic to any medications or vaccines? *

Yes
No

If yes, please specify *

Please describe your pet's demeanor *

Do you have your pet’s records? *

Yes
No

Previous clinic name: *

Have you scheduled an appointment with us yet? *

Yes
No

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings *

Sex *

Male
Neutered Male
Female
Spayed Female

What is your pet's current diet? *

Is your pet up-to-date on their vaccines? *

Yes
No

Is your pet currently taking any medications? *

Yes
No

If yes, please list the medication(s), including name, dosage, and frequency *

Has your pet had any previous illness or injury? *

Yes
No

If yes, please specify *

Is your pet allergic to any medications or vaccines? *

Yes
No

If yes, please specify *

Please describe your pet's demeanor *

Do you have your pet’s records? *

Yes
No

Previous clinic name: *

Have you scheduled an appointment with us yet? *

Yes
No

Do you have a third pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings *

Sex *

Male
Neutered Male
Female
Spayed Female

What is your pet's current diet? *

Is your pet up-to-date on their vaccines? *

Yes
No

Is your pet currently taking any medications? *

Yes
No

If yes, please list the medication(s), including name, dosage, and frequency *

Has your pet had any previous illness or injury? *

Yes
No

If yes, please specify *

Is your pet allergic to any medications or vaccines? *

Yes
No

If yes, please specify *

Please describe your pet's demeanor *

Do you have your pet’s records? *

Yes
No

Previous clinic name: *

Have you scheduled an appointment with us yet? *

Yes
No

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings *

Sex *

Male
Neutered Male
Female
Spayed Female

What is your pet's current diet? *

Is your pet up-to-date on their vaccines? *

Yes
No

Is your pet currently taking any medications? *

Yes
No

If yes, please list the medication(s), including name, dosage, and frequency *

Has your pet had any previous illness or injury? *

Yes
No

If yes, please specify *

Is your pet allergic to any medications or vaccines? *

Yes
No

If yes, please specify *

Please describe your pet's demeanor *

Do you have your pet’s records?

Yes
No

Previous clinic name: *

Have you scheduled an appointment with us yet?

Yes
No

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings *

Sex *

Male
Neutered Male
Female
Spayed Female

What is your pet's current diet? *

Is your pet up-to-date on their vaccines? *

Yes
No

Is your pet currently taking any medications? *

Yes
No

If yes, please list the medication(s), including name, dosage, and frequency *

Has your pet had any previous illness or injury? *

Yes
No

If yes, please specify *

Is your pet allergic to any medications or vaccines? *

Yes
No

If yes, please specify *

Please describe your pet's demeanor *

Do you have your pet’s records?

Yes
No

Previous clinic name: *

Have you scheduled an appointment with us yet?

Yes
No

May we have permission to share photos of your pet on our social media accounts? *

Yes
No

I acknowledge that all fees for services and/or products provided are DUE at the time they are performed, and I acknowledge that I am financially responsible for payment in full for the services and/or products at the time they are provided. I agree to pay any additional charges related to the cost of collection (including, but not limited to collection agency fees, reasonable attorney fees and court costs), in the event I would fail to pay my bill in full. *

I have read and acknowledge

Today's Date *

Website

Interested In Working
At Bear Creek?

Be a part of our veterinary team! We’re hiring passionate, caring, and positive pet lovers for all positions.

Bear Creek Animal Hospital front desk



Location

1215 W Pearce Blvd.
Wentzville, MO 63385



Contact Information

P: 636-538-6050
E: hello@wentzvilleanimalhospital.com



Hours

Monday – Friday: 8am – 6pm
Saturday: 8am – 1pm

We proudly serve the pets of Wentzville, MO, Stone Meadows, MO, Foristell, MO, and beyond.

pet-desk-graphic

Download our app and connect with us on PetDesk!

Keeping up with your pet’s health from your mobile device has never been easier! With our new app, you’ll have all of your pet’s health information in the palm of your hand. Plus, you’ll be able to communicate with us much easier. You’ll be able to:

Request Appointments 24/7
Receive Automatic Reminders
Save Notes, Pics, and Much More
Your Pet’s Free Organizer App

Have questions about our new app? Our contact information can be found on the bottom of this page!

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