New Client Form

Name: ZumiVet In-Home Veterinary Care
Address: 4629 Cass St, #359, San Diego, CA, 92109, USA
Telephone: (619) 897-7067

We’re excited to care for your pet. This form helps us prepare for a smooth, low-stress visit tailored to your pet’s needs. Most clients complete it in 3–5 minutes.

Owner's Name *

Email *

Primary Phone *

Secondary Phone *

To help us provide timely updates and easy communication, we use text messaging for scheduling, visit updates, and follow-up care.

I consent to receive text messages from ZumiVet regarding appointments, visit updates, and follow-up care. Message and data rates may apply. You can opt out at any time by replying STOP. *

Preferred contact method *

Text

Call

Email

Address

Address *

Address 2 *

City/Town *

State/Province *

ZIP/Postal Code *

Who else is authorized to make decisions about your pet's healthcare?

First

Last

Phone

How did you find out about our clinic? *

Google

Yelp

Facebook

Friend or Relative

Instagram

Veterinary Referral

Other…

Enter other…

Friend / Relatives Name:

Where was your previous vet clinic? *

Please type "NONE" or "N/A" if not applicable

I understand that I must contact my previous veterinarian(s) and request my pet's previous medical records be sent to ZumiVet by email to [email protected]. Not doing so will prevent my pet from receiving optimal care.

I have read and understand *

Pet's Name *

Species *

Breed *

Age/Date of Birth *

Sex *

Is your pet spayed or neutered? *

Yes

Age of pet when first acquired *

Does your pet have a microchip identification? *

Yes

Are you interested in having a microchip implanted at your pet's next appointment?

Yes

Current health concerns *

If yes, please explain.

Are there any concerns for the following:

Eating

Drinking

Diarrhea

Defecating

Vomiting

Coughing or Sneezing

Urinating

None

Other…

Enter other…

Behavioral concerns: *

If yes, please explain.

Has your pet ever shown signs of aggression towards people before (at home, outside or at a veterinary office. This includes hissing, growling, lunging, swatting, scratching and certain types of barking). *

Yes

If yes, please explain.

Has your pet ever been prescribed or was recommended to take an oral medication such as gabapentin or trazodone prior to veterinary visits to help reduce signs of fear, anxiety, stress or aggression? *

Yes

If yes, please explain.

Previous or ongoing illness or injury: *

Please type "NONE" or "N/A" if not applicable

Previous Surgery: *

Please type "NONE" or "N/A" if not applicable

History of abnormal vaccine reactions: *

Please type "NONE" or "N/A" if not applicable

Medical Allergies: *

Please type "NONE" or "N/A" if not applicable

What does your pet eat? (Please be as detailed as possible): *

Current medications or supplements: *

Please type "NONE" or "N/A" if not applicable

Current flea, tick or heart-worm prevention: *

Please type "NONE" or "N/A" if not applicable

Please list anything else you would like us to know about your pet: *

Please type "NONE" or "N/A" if not applicable

How does your pet typically do at the vet?

Very relaxed

Mildly nervous

Anxious

Fearful

Add an additional pet?

Yes

Pet's Name

Species

Breed

Age/Date of Birth

Sex

Is your pet spayed or neutered?

Yes

Age of pet when first acquired

Does your pet have a microchip identification?

Yes

Are you interested in having a microchip implanted at your pet's next appointment?

Yes

Current health concerns

If yes, please explain.

Are there any concerns for the following:

Eating

Drinking

Diarrhea

Defecating

Vomiting

Coughing or Sneezing

Urinating

None

Other…

Enter other…

Behavioral concerns:

If yes, please explain.

Yes

If yes, please explain.

Yes

If yes, please explain.

Previous or Ongoing Illness or Injury:

Please type "NONE" or "N/A" if not applicable

Previous Surgery:

Please type "NONE" or "N/A" if not applicable

History of abnormal vaccine reactions:

Please type "NONE" or "N/A" if not applicable

Medical Allergies:

Please type "NONE" or "N/A" if not applicable

What does your pet eat? (Please be as detailed as possible):

Current medications or supplements:

Please type "NONE" or "N/A" if not applicable

Current flea, tick or heart-worm prevention:

Please type "NONE" or "N/A" if not applicable

Please list anything else you would like us to know about your pet:

Please type "NONE" or "N/A" if not applicable

How does your pet typically do at the vet?

Very relaxed

Mildly nervous

Anxious

Fearful

Add an additional pet?

Yes

Pet's Name

Species

Breed

Age/Date of Birth

Sex

Is your pet spayed or neutered?

Yes

Age of pet when first acquired

Does your pet have a microchip identification?

Yes

Are you interested in having a microchip implanted at your pet's next appointment?

Yes

Current health concerns

If yes, please explain.

Are there any concerns for the following:

Eating

Drinking

Diarrhea

Defecating

Vomiting

Coughing or Sneezing

Urinating

None

Other…

Enter other…

Behavioral concerns:

If yes, please explain.

Yes

If yes, please explain.

Yes

If yes, please explain.

Previous or Ongoing Illness or Injury:

Please type "NONE" or "N/A" if not applicable

Previous Surgery:

Please type "NONE" or "N/A" if not applicable

History of abnormal vaccine reactions:

Please type "NONE" or "N/A" if not applicable

Medical Allergies:

Please type "NONE" or "N/A" if not applicable

What does your pet eat? (Please be as detailed as possible):

Current medications or supplements:

Please type "NONE" or "N/A" if not applicable

Current flea, tick or heart-worm prevention:

Please type "NONE" or "N/A" if not applicable

Please list anything else you would like us to know about your pet:

Please type "NONE" or "N/A" if not applicable

How does your pet typically do at the vet?

Very relaxed

Mildly nervous

Anxious

Fearful

I authorize ZumiVet to use my pet's name and photograph in any promotional or educational materials. *

I authorize

I do not authorize

Cancelation Policy: You can cancel your appointment up to 24 hours before your scheduled time. Canceling within 24 hours of a visit will incur a cancellation fee equal to the cost of the appointment type (ex: house call and exam fee, euthanasia fee, initial rehabilitation consultation fee, rehabilitation treatment fee). If your appointment was scheduled within 24 hours of the appointment, there is a 15 minute grace period to cancel the appointment. Please text or call us at (619) 897-7067 or email us at [email protected] to cancel or reschedule your appointment.

I have read and understand *

Credit Card Authorization: I authorize ZumiVet to charge the card on file for any applicable cancellation or no-show fees per the cancellation policy.

I have read and understand *

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