Client Forms and Educational Handouts

We now are able to accept online forms and ask that you fill the appropriate forms out online as requested by our customer service representative at least 24 hours ahead of your appointment. This will assure a much smoother appointment with minimal wait times once here. As always, please contact us with any questions.

New Client Registration

New Client Registration
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Preferred method of communication

New Pet Registration

New Pet Registration
Name
Name
First
Last
Sex
Do you or anyone in your family have any life-threatening allergies?
Does your pet have any allergies?

Maximum file size: 52.43MB

I do hereby authorize the veterinarian to examine, prescribe for and treat the above pet. I assume responsibility for all charges incurred in the care of the animal.

New Client Consent to Release Information

New Client Consent to Release Information
Name
Name
First
Last

Consent to Release Information Regarding your Pet

The state of New Hampshire requires pet owners give consent to release medical information regarding their pet. Your privacy is of utmost importance. If any medical record information is to be shared with boarding/daycare/grooming/insurance companies/veterinary hospitals we need your consent to do so. 

We can call you every time this occurs OR signing below with a YES or a NO you can direct consent on your pet's medical record should any of these facilities call. If you do not give us consent to release the information below, we will not release the information but we would call you instead before any consent would be given. Please keep in mind if you decide not to give consent, it is possible your pet may be declined for boarding, daycare, grooming, insurance reimbursement, and/or treatment until they receive the information they need. 

BOARDING/DAYCARE/GROOMING FACILITIES

Consent to release my pet's vaccine information to boarding/grooming/daycare facilities
Consent to release my pet's fecal Information, including results to boarding/grooming/daycare facilities

PET INSURANCE

Consent to release your pet's records to pet insurance providers

VETERINARY HOSPITALS/EMERGENCY VETERINARY HOSPITALS

Consent to release your pet's records to veterinary hospitals/emergency pet hospitals

ADOPTION AGENCIES/SHELTERS

Consent to release your pet's records to adoption agencies/shelters

New Client Written Prescription/Online Pharmacy

New Client Written Prescription/Online Pharmacy
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal

I hereby request a prescription for medication(s) for my pet so that I can purchase these products from an outside pharmacy. I have been informed that the following risks exist when I obtain these products from a source other than my veterinarian.

  • There is possibility that the prescription drugs received from these vendors may be counterfeit or may not have been approved by the FDA or EPA. These medications could be outdated, mislabeled, or improperly stored.
  • Pharmacists are not trained in veterinary medicine and medications could be under dosed, over dosed, or contain ingredients that are not safe for pets.
  • The number of tablets or capsules, milligram size of the unit, volume and/or concentration of liquid and number of authorized refills may differ from that prescribed by the attending veterinarian.
  • The manufacturer’s warranties or guarantees for these products may not be valid.  This means if your pet’s condition is not effectively treated with the product(s), manufacturers may not stand behind their products or product liability procedures.  Additionally, the owner and veterinarian at this facility may be unable to assist you in claims against those manufacturers.
  • I understand that this written prescription is a legal document and should be treated as such. I further understand that this document cannot be re-issued if lost or misplaced until refill date if applicable.  Also, in order to cancel this outside prescription and have indicated medications filled at this facility within the prescription(s)’ (or their refills’) time period I must return the prescription document to this facility to be disposed of.

I have read and understand the above, accept these risks, and am aware that this facility cannot accept any financial responsibility for paying for or reimbursing me for any treatments required as a result of the use of products purchased outside of this establishment. In the absence of negligence, I agree to hold this veterinary practice harmless for any deleterious effects or lack of effectiveness of drugs or vaccines purchased from any other source.

Dogs/Cats: Pre-Appointment Check in Questions

Dogs/Cats: Pre-Appointment Check in Questions

Please provide at least 24 hours prior to appointment

 
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
The information above is new and needs to be updated in Canobie Lake Veterinary Hospital's records.
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?

Note:
Masks are now optional to wear on the day of your appointment.

Exotics/Birds Only: Pre-Appointment Check in Questions

Exotics and Birds Only: Pre-Appointment Check in Questions

Please provide at least 24 hours prior to appointment

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
The information above is new and needs to be updated in Canobie Lake Veterinary Hospital's records.
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?

Note:
Masks are now optional to wear on the day of your appointment.

Returning Client Medical Progress Exam

Returning Client Medical Progress Exam

Please provide at least 24 hours prior to appointment

 
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
The information above is new and needs to be updated in Canobie Veterinary Hospital's records.
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?

Note:
Masks are now optional to wear on the day of your appointment.

Dental Admission Form

Dental Admission Form
Please provide at least 24 hours prior to appointment

Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment. For Exotics/Birds please call the hospital for withholding food and water instructions.

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?

Note:
Masks are now optional to wear on the day of your appointment.

I, the undersigned owner, or owner's authorized agent of the above pet certify that
Is your pet on medication?
I have been informed that my pet is in need of preventive or therapeutic dental care and hereby consent to the appropriate procedures described to me by the veterinarian and her staff at this facility. These procedures include but are not limited to the following: 1) dental prophylaxis (routine teeth cleaning and polishing), 2) extractions, 3) oral surgery to close gaps left by extractions, 4) root planings, 5) dental x-rays, and 6) antibiotic gel implants.
I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) provide for the safety of the pet, doctor, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before these procedures are initiated.
Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff:
I have been informed that examinations under anesthesia often reveal dental disease and abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other.
Please choose one of the following
I understand that a treatment plan of the fees for the above procedures will be emailed to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to pay and assume financial responsibility for the balance of services rendered, and agree to provide payment of cash or credit card on the day of service. I understand full payment is required at the time of service

We prefer that you take your pet’s belongings (collar, leash, etc..) home with you.

I will take my pet’s belongings home with me (leashes, sweater, toy etc.):
If it is recommended for your pet to go home with oral medications would you prefer (sometimes liquid is not available for some medications)
In addition to this estimate I would like the following procedures to be performed on my pet, while he/she is under anesthesia and or sedation today and I agree to be responsible for the additional cost of these items as listed below

Surgical Admission Form

Surgical Admission Form

Please provide at least 24 hours prior to appointment

 

Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment. For Exotics/Birds please call the hospital for withholding food and water instructions.

Name
Name
First
Last
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?

Note:
Masks are now optional to wear on the day of your appointment.

Is your pet on medication?
I, the undersigned owner or agent of the owner of the pet identified above, certify that
I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

  • The reasonable medical and/or surgical treatment options for my pet
  • Sufficient details of the procedures to understand what will be performed
  • How fully my pet will recover and how long it will take
  • The most common and serious complications
  • The length and type of follow-up care and home restraint required
  • The estimate of the fees for all services
  • Any necessary payment arrangements
While I accept that all procedures will be performed to the best of the abilities of the veterinarian and the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff

I understand that a treatment plan of the fees for the above procedures will be emailed to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to pay and assume financial responsibility for the balance of services rendered, and agree to provide payment of cash or credit card on the day of service. I understand full payment is required at the time of service.

In the event my pet is hospitalized beyond the day admission at this facility, I understand that veterinary care during nighttime hours and/or weekends is not provided at this facility. If my pet needs overnight hospitalization and I do not want to have my pet hospitalized when this facility is closed and no veterinary staff are present to supervise in the facility, I elect to

I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed.

We prefer that you take your pet’s belongings (collar, leash, etc..) home with you.
I will take my pet’s belongings home with me(leashes, sweater, toy etc.)
If it is recommended for your pet to go home with oral medications would you prefer (sometimes liquid is not available for some medications)
In addition to this estimate I would like the following procedures to be performed on my pet, while he/she is under anesthesia and or sedation today and I agree to be responsible for the additional cost of these items as listed below

Medical Day Admission Form

Medical Day Admission Form

Please provide at least 24 hours prior to appointment

Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment. For Exotics/Birds please call the hospital for withholding food and water instructions.

 

Name
Name
First
Last
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?

Note:
Masks are now optional to wear on the day of your appointment.

Is your pet on medication
I, the undersigned owner, authorized agent of the owner or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that
Please choose one of the following

I also agree that after consultation with me, the veterinarian may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on this animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff:

I understand that a treatment plan of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees attendant to such care before services are rendered and during this pet's ongoing medical treatment. If this animal is hospitalized, I agree to pay and assume financial responsibility for the balance of all services rendered by cash or credit card at the time the pet is discharged from the hospital. I understand full payment is required at the time of service. 

In the event my pet is hospitalized beyond the day admission at this facility, I understand that veterinary care during nighttime hours and/or weekends is not provided at this facility. If my pet needs overnight hospitalization and I do not want to have my pet hospitalized when this facility is closed and no veterinary staff are present to supervise in the facility, I elect to:

I further agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges at the time of pick up. If other payment arrangements were made during the hospitalization it must be agreed upon by myself and the veterinarian or veterinary staff and documented in my account. I agree that if I fail to comply with this policy, this practice may handle this abandonment in the best interests of the pet and the hospital, and I will be responsible for all fees incurred.

Physical Rehabilitation Intake Form

Physical Rehabilitation Intake Form

Physical Rehabilitation Intake Form

We are excited to see your pet for their initial rehab consult! Please fill out this form at least 24 hours prior to their initial appointment. By doing so, this will allow us more time at your visit to discuss any recommended rehab program, go over initial exercises, and answer questions. Some questions are marked as required. Others are optional but the more information we have, the better we will be able to tailor the rehab program to your pet's individual needs.

If your pet has had diagnostics or treatments for the presenting problem at hospitals other than Canobie Lake Veterinary Hospital, please make sure to request that they send all relevant records (including x-rays and labwork) to us. If we have not received records at least 24hours in advance of the appointment, we will contact you to reschedule your appointment to a later date to allow time for these to be reviewed prior. 
First
Last
Gender

Lifestyle/Diet

There is no wrong or right answer to these. Knowing your pet's normal lifestyle can help us design the best individualized rehab plan.
General activity level of your pet (this refers to normal activity prior to any current injury or surgery). Check all that apply.
Home Setup. Please check off any of the below that apply to your pet's home environment.
Any food allergies?

Current Restrictions/Rehab

This will mostly apply to pets in recovery from surgery or an injury. Can leave blank if this does not apply.
Is your pet currently under activity restriction?
Are you doing prescribed leash walks?
Are you doing any rehab exercises already?

Rehab Goals

Knowing your pet's current challenges and your goals for rehab will help us design the best rehab plan to try to meet those goals.
Does your pet have difficulty with any of the following? Check all that apply. Check only if a challenge for them. Do not check if able to do them but currently under activity restriction recommendations not to.
Are you concerned that your pet is in pain?
a corgie with their tongue sticking out running

Educational Handouts for Exotic Pet Owners

Did you recently bring home a new rabbit, guinea pig, or tortoise? Whether you’re a new or experienced exotic pet owner, you may have questions about how to best care for your companion. That’s why we’ve provided the following client handouts to help educate pet owners and answer some of the most frequently asked questions.

Birds
Backyard Poultry CareBird Care

Small Mammals

Chinchilla Care

Ferret Care

Guinea Pig Care

Hamster and Gerbil Care

Rabbit Care

Rat Care

Sugar Glider Care

Reptiles

Bearded Dragons Care

Boa Care

Freshwater Turtle Care

Iguana Care

Leopard Gecko Care

Skink Care

Tortoise Care

Water Dragon Care

Please give us a call at 603-898-8982 if you have any questions about these handouts. You can also visit our exotic pet pages for more information.