New Client Information

IMPORTANT: Please call us at 816-229-1544 to make an appointment prior to completing the New Client Information Form. Submitting the form will not reserve or request an appointment.

Contact Information

Please provide current and accurate contact information. Our doctors may need to call you for lab results or other important patient information. We send appointment confirmations and reminders by email and/or text message. We will not spam or share your email or cell phone.

Date*

Name*

First Last

Spouse / Significant Other

First Last

Primary Phone*

Mobile Phone (if different from Primary Phone)

Spouse / SO Phone

(optional)

Employer

Work Phone

(Optional)

Address*

Street Address Address Line 2 City State ZIP Code

Email*

We will not share or spam your email.

Enter Email Confirm Email

Why did you choose us?*

Whom may we thank?

Pet Information

Patient Name*

Patient Species*

Dog
Cat

Patient Sex*

Female
Female Spayed
Male
Male Neutered

Patient Breed*

Patient Color*

Patient Birthday or Age*

Last Vaccinated?*

Do you have another pet to add?*

Yes
No

Patient Name*

Patient Species*

Dog
Cat

Patient Sex*

Female
Female Spayed
Male
Male Neutered

Patient Breed*

Patient Color*

Patient Birthday or Age*

Last Vaccinated?*

Do you have another pet to add?*

Yes
No

Patient Name*

Patient Species*

Dog
Cat

Patient Sex*

Female
Female Spayed
Male
Male Neutered

Patient Breed*

Patient Color*

Patient Birthday or Age*

Last Vaccinated?*

Medical Records

If possible please upload or bring previous medical records including vaccine history, lab work and Xrays to your visit. Also bring any medications your pet is currently taking or has previously taken.

Upload Records

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 256 MB, Max. files: 6.

Is this appointment for a 2nd opinion on your pet's medical condition?*

Yes
No

Describe the problem that is prompting you to seek a second opinion.*

How long has this been a problem?*

How many other veterinarians have treated your pet for this problem?*

Describe any previous diagnostic tests and the results if you know them.

List any previous medications or treatments for this problem and describe how your pet responded.

Payment Policy

Blue Springs Animal Hospital accepts

Our payment policy is "payment when services are rendered." How will you be paying for services at your appointment?*

Credit or Debit Card
Personal Check
Cash

Does your pet have pet health insurance?*

Yes
No

Insurance Company

We require an adult who is financially responsible for the pet to be present at the appointment. I am 18 years or older and I am financially responsible for this pet.*

Yes
No

Please explain:

Notes or Special Instructions

CAPTCHA

Contact Information

Pet Information

Medical Records

Payment Policy

Blue Springs Animal Hospital accepts

Notes or Special Instructions

Connect With Us