Gamble Pet Clinic

Please feel free to contact us with any questions.

2108 Midpoint Dr., Suite 4
Fort Collins, CO 80525

Phone: (970) 221-9995
Fax: (970) 221-9978
Email: gamblepetclinic@digis.net

Hours:
Monday through Friday 7am-6pm
If you have an emergency during our business hours, please call us.
For after hours emergencies please call Fort Collins Veterinary Emergency Hospital at:
(970) 484-8080
They are located at 816 S. Lemay.

[ NEW CLIENT FORM | PATIENT MEDICAL HISTORY ]

[ RECOMMENDED DOGGY DAYCARE | RECOMMENDED BOARDING KENNELS | MAP/DIRECTIONS]

Client Information

Thank you for choosing our clinic for your pet's care. So that we may become better acquainted, please carefully print and complete the following both sides of this information sheet OR fill out this electronic form and submit it. If you have any questions, please do not hesitate to ask our Client Care Provider for assistance.

An * marks a required field.

Owner's Name:	*	Spouse/Partner:
Children (first name and ages):
Address:	*
City:	*	State: * Zip: *
Home Phone:	*	Spouse Phone(if different from above):
Work Phone:		What phone number would you like us to call you at regarding your pet:
Cell Phone:
In case of EMERGENCY, please call:		at phone number:
Do you have pets other than the ones we are seeing today?
YesNo	If so, what are they?
How did you first hear about our clinic?
Individual: someone we may thank?
Hospital Sign
Yellow Pages
Web Page
Other:
Would you like to receive your pet's reminders via e-mail?			YesNo
If so, please provide us with your email address:
Professional fees are to be paid at the time services are rendered. We do not carry open accounts and hope that these alternatives are convenient to you: cash, check, Visa, MasterCard and Discover. If you will be paying by check at any time, please complete the following information:
Social Security Number:
OR
Driver's License: State Number Exp
It is our policy to provide you with a written estimate of fees for any case where in-hospital treatment, emergency care, surgery or hospitalization will be provided. A deposit prior to treatment may be required.
I would like to be called to schedule an appointment

Patient Information (please complete all information for each pet)
	Pet #1	Pet #2
Name	*
Species (cat,dog)	*
Breed	*
Description (color)
Date of Birth or Age	*
Sex	*
Length of Time Owned
Altered or Spayed
Vitamins or Supplements
Diet (Kind of Pet Food)
Type of Grooming Products
Hours spent outside each day
VACCINATIONS Da2ppv(distemper-dog) FVRCP (infectious disease-cat) Rabies (dog/cat) Other Vaccines
Date and result of FeLV/FIV Test (cats)
Date and result of Heartworm Test (dogs)
Heartworm Preventative (brand)
Date and result Fecal Exam
Date of last Dentistry
Any Prior Illnesses
Any Prior Surgeries
Previous Veterinary Clinic Name
Travel History outside Colorado
PET ORIGIN	Humane Society Pet Shop Kennel Advertisement	Friend Stray Individual (nonbreeder) Breeder