New Clients

Hello, and welcome to Pet Cancer Therapy. We look forward to meeting you and helping your pet on its journey to better health.

A comprehensive medical history is very important and allows us to use your appointment time more efficiently as we do not have to ask for all of the information then. This allows more time to focus on an exam and treatment plan for your pet.

Past medical records often provide essential information that helps us create the best treatment plan for your pet. Please have your veterinarian(s) email your pet’s pertinent records to us. We will also transfer our records to other veterinarians you see so that they stay fully informed about your pet’s care.

In order to review your pet’s history prior to your appointment, please complete and return this form (and email any pertinent medical records) 72 hours in advance of your appointment.

Note: Required fields are marked with an asterisk (*)

Your Information:
First Name* Last Name*
City* State* Zip*
Phone* Email*
What other clinic(s) have you been to?*
*NOTE* Please have clinic(s) email pertinent medical records prior to your appointment
How did you hear about us?*

Who may we thank for your referral?
What keywords did you search on?
Whose Facebook page referred you?
Whose LinkedIn page referred you?
Which YouTube video did you watch?
Which Podcast did you listen to?
Which webinar did you watch?
Whose website referred you?
Please let us know how you found us.

What is your goal for this visit?*

Your Pet's Information:
Pet Name*    DOB (if known)
Age*    Sex*    Weight* lbs
Species*    Color*    Breed*
How long have you had your pet?*
Is your pet neutered?*    If yes, at what age?
When was your pet last vaccinated?
What is the reason for your pets visit?*
Is you pet currently being treated for this condition, and if so, what is the treatment?*
Other than listed above, what other medications and supplements is your pet taking?*
What food do you feed your pet? Please be as specific as possible and include treats:*
Has your pet had any of the following symptoms? If yes, check any/all that apply:
Mouth OdorRubbing at mouthSkin OdorScratching or chewing at skinLumps, bumps or rashesCoughingSneezingVomitingDiarrheaChanges in eating or drinkingChanges in urinationLimping or changes in gaitOther behavioral changes
Please provide any details on above symptoms, or any others that you have noticed:

Form Submission:
To avoid computer-generated submissions, answer the following random question*: