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Home
Our Hospital
- Our Staff
Pet Owners
- New Patient Form
Veterinarian Referrals
- Veterinary Referral Form
Services
Contact Us

Request an Imaging Appointment 920-560-3374

Home » New Patient Form

New Patient Form

Thank you for considering Health Veterinary Imaging for your pet’s specialty case. Please fill out our new client/patient registration form in entirety to ensure we can provide you and your pet with the best possible care.

Step 1 of 2

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Have you ever brought your pet to Health Vet Imaging or CountrySide Veterinary Services?(Required)

Yes

No

What service are you requesting?

Owner's Name(Required)

First

Last

Email(Required)

Primary Contact Number(Required)

Secondary Contact Number

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

How would you prefer to be contacted?(Required)

Primary Phone

Secondary Phone

Emails

Other

Is There Another Person Or Family Member Who Should Be Listed On Your Account?

First

Last

How did you hear about us?

Referring Veterinarian

Other Veterinary Professional

Personal Recommendation (word of mouth)

Google

Facebook

Instagram

Hospital Website

Nextdoor

Yelp

Other

Emergency Contact(Required)

First

Last

Phone(Required)

Pet's Name(Required)

Pet's Date of Birth (Approx.)(Required)

Pet's Sex(Required)

Male

Female

Neutered Male

Spayed Female

Species(Required)

Canine

Feline

Breed(Required)

Color

Pet Photo (optional)

Max. file size: 50 MB.

Is Your Pet Microchipped?(Required)

Yes

No

Unsure

Referring Veterinary Hospital Name(Required)

If you DO NOT have a Referring Veterinarian, please write “None”

Referring Veterinarian (Doctor) Name (If Known)(Required)

Primary Veterinarian Name (Doctor & Hospital)

IF DIFFERENT from your Referring Veterinarian

What Is The Primary Reason For This Referral?(Required)

Do You Think Your Pet Will Require Anti-Anxiety Medications To Be Given Prior Their Appointment?(Required)

Yes

No

Unsure

Do You Have Any Other Concerns That We Should Be Aware Of Prior To Your Pet's Appointment?(Required)

Has Your Pet Seen Another Specialist In The Past For This Referral?*(Required)

Yes

No

Other

Are There Another Veterinarian Who Has Treated Your Pet In The Past And You Would Like Reports Sent To?(Required)

Yes

No

Do You Already Have A Scheduled Appointment?*(Required)

Yes

No

Other

Upload Veterinary Records (Optional)

Max. file size: 50 MB.

If available, please upload medical records, test results, imaging studies relevant to your pet’s visit.

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Request an Imaging Appointment

Veterinary Referral

Pet Owners

Find Us

Request an Imaging Appointment 920-560-3374

Health Veterinary Imaging

2101 East Evergreen Drive,
Appleton, WI 54913

Business Hours

Monday

8:00am - 4:00pm

Tuesday

8:00am - 4:00pm

Wednesday

8:00am - 4:00pm

Thursday

8:00am - 4:00pm

Friday

8:00am - 4:00pm

Saturday

Closed

Sunday

Closed

by Appointment Only

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