New Clients: Please fill out the following form. If you have more than one pet you will need to fill out this form for each pet.
We look forward to meeting you and your pet while welcoming you into our family here at Ponemah!
Owner’s First Name *
Owner’s Last Name *
Co-Owner’s First Name *
Co-Owner’s Last Name *
How did you hear about us? *
Would you like us to call you for your appointment? Please Select an AnswerYesNo
Do you have records of your pets’ medical records? Please select an answerYesNo
Name of former veterinary practice?
Reasons that prompted your visit?
Special requests or conditions?
Please list the names of all person(s) who have permission to authorize treatment for your pets
Pet’s Name *
Type of Pet * Please select an asnwerCanineFelineFerretRabbitRatGuinea PigHamsterChinchillaMouseOther
Date of Birth *
Sex * Please select an answerMaleFemale
Are Your Pet’s Vaccines up to date? * Please select an answerYesNo
Does your cat go outside? *
Is your cat/dog on heartworm preventitive? * Please select an answerYesNo
Is your cat/dog on flea/tick preventitive? * Please select an answerYesNo
Your pet is: Please select an answerA member of our familyA child’s petA backyard pet
What brand & formula of food do you feed your pet? *
Do you brush you pet’s teeth? Please select an answerYesNo
If so how often? Please select an answerYesNo
Date of last dental cleaning?
Please list any medications, illnesses, previous surgeries, allergies, or any specific concerns:
3 + 0 = ? Please prove that you are human by solving the equation *
0 + 3 = ? Please prove that you are human by solving the equation *
199 Route 101, Building 8
Amherst, NH 03031
Phone: (603) 673-5300
Fax: (603) 673-5353
Mon & Wed: 8am – 7pm
Tues, Thurs, Fri: 8am – 6pm
Saturday: 8am – 1pm