New Client Form
Dr. Stanley's service zone currently includes: West Sonoma County, Santa Rosa and surrounding cities, and Petaluma.
Client Information
All information provided is confidential and will not be used for any purpose other than responding to your inquiry, and is needed to provide an estimate of costs for services.
Full Name
*
First Name
Last Name
Address for the house call:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Can you receive text messages and do you consent to receive appointment information and doctor communications?
*
Yes
No
E-mail
*
example@example.com
Special arrival instructions/requests:
Gates, parking, text on arrival, etc.
Patient Information
Patient Name:
*
Appointment Type:
*
Please Select
Standard Exam (initial)
Standard Exam (follow-up)
Integrative Medicine Exam/Acupuncture (initial)
Integrative Medicine Exam/Acupuncture (follow-up)
Vaccinations
Telemedicine
Quality of Life Consultation/Possible Euthanasia
Reason for appointment:
*
Please provide a detailed description. The more information the doctor has the better!
Species:
*
Please Select
Canine
Feline
Reptile/Amphibian
Small Mammal
Bird
Fish
Horse
Other
Breed/Type:
*
For exotic animals, please be as specific as possible.
Color/Markings:
Sex:
*
Please Select
Male (neutered)
Male (intact)
Female (spayed)
Female (intact)
Juvenile/Indeterminate
Approximate age or birthdate if known:
*
Please include units, i.e. years, months, weeks
Approximate weight:
Please include units, i.e. lb, oz, g
Approximate date of or time since last vet visit:
Previous records:
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Patient Photo
I have additional animals I would like to add to this house call.
Yes
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