New Patient Registration

Veterinary Healing Arts
New Patient Form
Nameyour full name
Partner's NameIf you would like us to include someone on your record
Pet's Name
Your Pet Is:pick one!
If Other, What:
Your Home Addressyour street address
City, State, and Zipplease provide all of these
Your Phone NumberPlease provide the best number to reach you at
Emergency Contact NameNot Dr. Rimar
Emergency Contact's Phone
How Did You Hear About Us?pick all that apply
If someone referred you, please tell us who:
Tell Us More About Your Pet
BreedPlease give us your best guess
Color/MarkingsPlease describe your pet
Is Your Petpick one!
Your Pet's Microchip Number
Your Pet's BirthdayApproximately if you don't know precisely
Your Current Veterinarian
Your Veterinarian's Phone Number
Heartworm MedicationName of Product and Most Recent Dose

All dogs, cats, and ferrets in Florida are at extreme risk of being infected by heartworms, a deadly disease transmitted by a mosquito bite.

It is crucially important that your pet be given a monthly preventative for protection. If you do not currently have a heartworm preventative, please ask us for information.

Flea/Tick PreventionName of Product and Most Recent Dose
Reason for your visit?Please give us a brief explanation
0 / 300
Current MedicationsConventional and Alternative
0 / 1000
Any of the following a problem?Please pick all that apply
What Foods Do You Feed Your Pet?
What Treats Do You Give Your Pet?
How Often Do You Give Treats?
What Grooming Products Do You Use?
How Often?in general
Other Pets?Please list other pets by name, species and breed that live with you
0 / 2000
Vaccination HistoryTo the best of your memory, please list vaccinations given, date they were given, and by which Veterinarian. You can also have your Vet email us a history at
0 / 5000

We are pleased to welcome you to our practice and include you in the Veterinary Healing Arts circle of friends. It is important that your pet is current on all of his/her vaccinations except if vaccination poses a detrimental medical risk.

It also important that your pet be free of internal parasites such as worms and external parasites like fleas, ticks, and ear mites. We have many safe and effective resources for you to use to keep you, your pet, and our other clients free from infestation – just ask!

If we are not satisfied that your pet meets the necessary health conditions, we will test and treat your pet for all parasites; this is a public health issue and is for the protection of your pet as well as our other clients.

Please check the box below and type your name to acknowledge that you understand this requirement and that you accept financial responsibility for your pet.

I understand the above statements and I agree to them
Type Your NameTo signify your agreement
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If you have any questions please give our office a call.