New Client Info

Dix Hills Animal Hospital offers our new patient form online so you can complete them in the convenience of your own home or office. Simply fill out the form below, and we will receive your submission electronically.

New Client Info

Client Information

Were you referred by a family member or friend?

Pet Information

Number of Pets *

Pet 1

Dog/Cat *
Is your pet under one year of age?
Spayed/Neutered? *
Male/Female *

Pet 2

Dog/Cat *
Is your pet under one year of age?
Spayed/Neutered? *
Male/Female *

Pet 3

Dog/Cat *
Is your pet under one year of age?
Male/Female *
Spayed/Neutered? *

Pet 4

Dog/Cat *
Male/Female *
Spayed/Neutered? *
Is your pet under one year of age?

New Puppy Questionnaire - Pet 1

HAVE YOU RAISED A PUPPY BEFORE?
HAS YOUR PUPPY EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
WOULD YOU LIKE US TO TEACH YOU HOW TO CLEAN YOUR PUPPY’S EARS, TRIM NAILS OR BRUSHING THEIR TEETH EITHER TODAY OR AT A FUTURE VISIT?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
DO YOU PLAN ON TAKING THIS PUPPY TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
WILL THIS PUPPY BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Puppy Questionnaire - Pet 2

HAVE YOU RAISED A PUPPY BEFORE?
HAS YOUR PUPPY EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
WOULD YOU LIKE US TO TEACH YOU HOW TO CLEAN YOUR PUPPY’S EARS, TRIM NAILS OR BRUSHING THEIR TEETH EITHER TODAY OR AT A FUTURE VISIT?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
DO YOU PLAN ON TAKING THIS PUPPY TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
WILL THIS PUPPY BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Puppy Questionnaire - Pet 3

HAVE YOU RAISED A PUPPY BEFORE?
HAS YOUR PUPPY EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
WOULD YOU LIKE US TO TEACH YOU HOW TO CLEAN YOUR PUPPY’S EARS, TRIM NAILS OR BRUSHING THEIR TEETH EITHER TODAY OR AT A FUTURE VISIT?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
DO YOU PLAN ON TAKING THIS PUPPY TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
WILL THIS PUPPY BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Puppy Questionnaire - Pet 4

HAVE YOU RAISED A PUPPY BEFORE?
HAS YOUR PUPPY EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
WOULD YOU LIKE US TO TEACH YOU HOW TO CLEAN YOUR PUPPY’S EARS, TRIM NAILS OR BRUSHING THEIR TEETH EITHER TODAY OR AT A FUTURE VISIT?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
DO YOU PLAN ON TAKING THIS PUPPY TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
WILL THIS PUPPY BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Canine Questionnaire - Pet 1

HAS YOUR PET EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
IS YOUR PET CURRENTLY TAKING HEARTWORM PREVENTION?
IF SO DO YOU NEED A REFILL?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
DO YOU PLAN ON TAKING THIS PET TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
WILL THIS PET BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Canine Questionnaire - Pet 2

HAS YOUR PET EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
IS YOUR PET CURRENTLY TAKING HEARTWORM PREVENTION?
IF SO DO YOU NEED A REFILL?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
DO YOU PLAN ON TAKING THIS PET TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
WILL THIS PET BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Canine Questionnaire - Pet 3

HAS YOUR PET EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
IS YOUR PET CURRENTLY TAKING HEARTWORM PREVENTION?
IF SO DO YOU NEED A REFILL?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
DO YOU PLAN ON TAKING THIS PET TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
WILL THIS PET BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Canine Questionnaire - Pet 4

HAS YOUR PET EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH WHAT HEARTWORM DISEASE IS AND HOW TO USE PREVENTION?
IS YOUR PET CURRENTLY TAKING HEARTWORM PREVENTION?
IF SO DO YOU NEED A REFILL?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?
DO YOU HAVE ANY RACCOONS, OPOSSUMS OR RODENTS IN YOUR BACKYARD? (THIS DOES NOT INCLUDE RABBITS OR SQUIRRELS)
ARE YOU IN A TICK PREVALENT AREA? DO YOU FREQUENTLY FIND TICKS ON YOURSELF?
DO YOU PLAN ON TAKING THIS PET TO PARKS, OUT EAST, UPSTATE FIRE ISLAND OR ANY OTHER AREA THAT HAS AN INCREASED POPULATION OF TICKS OR WILDLIFE?
WILL THIS PET BE GETTING GROOMED, BOARDED, BROUGHT TO DAYCARE OR TRAINING CLASSES?

New Kitten Questionnaire - Pet 1

HAS YOUR KITTEN EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?

New Kitten Questionnaire - Pet 2

HAS YOUR KITTEN EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?

New Kitten Questionnaire - Pet 3

HAS YOUR KITTEN EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?

New Kitten Questionnaire - Pet 4

HAS YOUR KITTEN EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU FAMILIAR WITH USING FLEA AND TICK PREVENTION?

New Feline Questionnaire - Pet 1

HAS YOUR CAT EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?

New Feline Questionnaire - Pet 2

HAS YOUR CAT EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?

New Feline Questionnaire - Pet 3

HAS YOUR CAT EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?

New Feline Questionnaire - Pet 4

HAS YOUR CAT EXPERIENCED ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)
ARE YOU INTERESTED IN LEARNING ABOUT PET INSURANCE TODAY?
ARE YOU CURRENTLY USING FLEA AND TICK PREVENTION?
DO YOU NEED A REFILL?

Current Veterinarian

Would you like us to contact a previous vet for records for your pet?
I understand that payment is expected at the time services are rendered. I hereby authorize the staff of Dix Hills Animal Hospital to render any treatment which is deemed necessary to the health of my pet(s) while in custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representatives before, if time permits, proceeding with the treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that a deposit is required for all pets admitted to the hospital. I understand that if my account is not kept in good standing, a finance fee of $25 will be added to the account and it will be forwarded to a third-party collections agency, which may affect my credit rating. I understand that photos/videos may be taken of my pet for training or marketing purposes.

Get the best care for your best friend.

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