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About Dr. Curtis
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New Patient Form

IMPORTANT: Please fill out a new form for each individual pet

Download and fill out our PDF form or proceed to the next section:

If using pdf method, please download your filled-out pdf form when finished and email to curtisvet1@gmail.com. Thanks!!

Pet's Name *

Pet's Birthdate *

Pet Type *DogCatOther

If other, what type?

Pet Breed

Pet's Gender *MaleFemale

Your First/Last Name *

Email Address *

Street Address *

City

State/Province

ZIP / Postal Code

Country

Phone Number *

Please provide instructions for the doctor's vehicle parking within 1 block of your home. Any parking fees in excess of $5 are added to the home visit fee.

Pet''s Medical History

Instructions: What follows are guidelines for creating a summary of your pet’s medical history. While I will also want to review relevant medical records from veterinary providers, I am as much interested in YOUR viewpoint.

Health Summary, please provide a detailed summary of your concerns regarding your pet’s health: *

Specific Concerns, please provide a list of past medical concerns (illnesses, surgeries, etc), including approximate dates of occurrence. If certain problems recur frequently, please indicate that as well: *

Diet, please provide specifics about your pet(s) usual diet (past and present): *

Medicines and Supplements, please provide a current list of medications and supplements/vitamins. Indicate dosage and frequency as well. Helpful to have medications and supplements available for review during the appointment: *

Vaccination History: Please provide vaccination history for last 5 years:

Rabies *

Distemper Combo *

Lyme *

Bordatella *

FVRCP *

FELV *

Titer Results *

Other

Please describe any history of biting, scratching or behavioral aggression:

Please have your veterinary providers email (curtisvet1@gmail.com) any relevant medical records from at least the last 12 months. I may request additional medical records during our visit.

Authorization Agreement *AgreeAs the owner or authorized agent of the pet described above, I hereby authorize Dr. Kimberly Curtis and staff of Handle With Care Home Veterinary Service, PC to perform the services I request, and all other procedures, diagnostics, treatments, and/or administration of prescription medications and over the counter medications/supplements (both label and off-label) within accepted veterinary guidelines as deemed advisable and/or necessary for my pet(s). Dr. Curtis and staff will take every reasonable action to ensure the success of my pet’s treatment/procedure, but the possibility of death as a severe complication of any procedure does exist. There is no guarantee, nor can one be made as to the results or cure of any therapy. I agree to pay, in full, for any and all services rendered at the point of service. I understand and agree to the terms of Handle With Care Home Vet’s cancellation policy.

I agree to:

AgreeAssure patient is in an area where they cannot hide or leave the home at the time of examination and treatment

AgreeProvide a well lit area for examination and treatment

AgreeSeparate other pets from the treatment area during examination or treatment, unless otherwise authorized by the doctor

AgreeProvide payment at the time services are rendered. A 3.5% fee assessment to any Credit Card or PayPal payments.

Cancellation Agreement

Do you understand and accept these terms? *YesNo

Handle With Care Home Veterinary Services

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