Online Client Forms

We are a technology driven practice allowing you to submit your requests and questions when you have the time to do so. Below are the most common forms that you’ll use. Please contact us here if you have questions about these forms or would like for us to give you a call!

Appointment Request Form

Appointment Request

Are you an existing client and have visited our hospital in the last 12 months? *

Yes

We want your pet to receive the type of care that is right for them and you so please click here to tell us about you and your pet. Once we have reviewed your information (within 5-10 days), we will be in touch! New client appointments are in high demand and often are booked more than a month in advance.

If your pet needs urgent medical care that cannot wait, please see the emergency/urgent care section of our website for further instructions.

Would you like to use our mobile app to request your appointment? *

Yes

No, but I would like to download it and use it now

I do not have the app and would like to continue with this request form.

Pet Owner Name (must be over 18 years of age) *

Pet Owner Name (must be over 18 years of age)

First

Last

Mobile Phone Number *

Email *

Patient's Name *

Briefly tell us what your pet needs an appointment for (i.e. scratching ears, not eating well, healthy lifestyle visit, preventative care, etc.) *

What days of the week or times of the day (morning or afternoon) do you prefer? (i.e. Wednesdays are best, any day before noon works for me) *

Does your pet need any special accommodations for their visit (i.e. doesn't like other dogs, needs help getting out of the car, etc.)? *

Click here to go to our app!

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New Client Application

New Client Form

Visit our New Cat Client Page to learn more about what to expect from us and then submit your new client application.

Name *

Name

First

Last

Address *

Address

City

State

Zip

Mobile Phone Number *

Email *

Does this phone accept text messages? *

Yes

Your primary email for the doctor to send your pet's report and discharge instructions *

Other Responsible Party (second pet parent in home, or if a single pet parent family your emergency contact person) *

Other Responsible Party (second pet parent in home, or if a single pet parent family your emergency contact person)

First

Last

Second Party's Mobile Phone Number *

Second Party's Email *

Does this phone accept text messages? *

Yes

How did you first learn of our hospital?

Facebook

Instagram

Google / Web Search

Drive-by

Fear Free website

American Feline Practitioners Website

Personal Recommendation

OtherOther

Whom may we thank? *

Previous Veterinary Clinic Name/Names *

Previous Veterinary Clinic's Town and State *

Pet's Name *

Pet Species *

Dog

Cat

Breed *

Color *

Sex *

Male

Neutered Male ("fixed")

Female

Spayed Female ("fixed")

Birthdate or Approximate Age *

Show us your friend and upload a photo here! We use profile pictures in our medical records and would love a photo of them being super cute at home!

Maximum file size: 52.43MB

Is your pet microchipped? *

Yes

If yes, what is your pet's chip number? *

Our instagram handle is @healingpawsveterinary - does your pet have an Instagram handle? *

Yes

If yes, What is your pet's IG handle? *

We can't wait to meet your pet! What makes them a great companion and friend? *

What is the first appointment type you need to schedule for your friend? (Check all that apply) *

Healthy pet exam - including recommended vaccinations & laboratory testing

First time puppy or kitten visit

Vomiting/diarrhea

Allergies/skin disease consultation

Skin evaluation for a new problem

Skin evaluation - second opinion for repeating problem

Nutrition consultation

Urinary issues

Eye issues

Limping, leg/paw issues

Dental/oral health issues

Ear issues

Changes in bathroom habits

Changes in appetite

Check lump or skin growth

Weight loss or gain

Quality of life consultation

End of life care

OtherOther

Please upload any medical records or vaccine history that you have for your pet here. You may submit this application without uploading files now but you must either upload your records or send them by email to team@healingpawscarlisle.com in order for an examination to be scheduled. The only pets that will be scheduled without us receiving medical records are newly adopted pets who have never been vaccinated or seen by a veterinarian. Thank you for getting your pet's records to us quickly so that we can schedule them for the appropriate care that they need.

Maximum file size: 52.43MB

Do you have any other cats or dogs in your household? *

Yes

Please tell us their names, ages, sex, species and breeds *

When choosing a veterinarian for your pet, what is important to you? *

When choosing a pet food, what is important to you? *

I am the legal owner or responsible party seeking veterinary care for the pet/pets identified and I certify that I am eighteen years of age or over. *

I have read, understand, and agree to the above statement

At Healing Paws Veterinary Care, we recommend regular examinations, vaccinations, commercially prepared balanced pet foods, parasite prevention, regular dental hygiene procedures, and, when needed, collaboration with board-certified veterinary specialists to ensure your pet receives the very best care. Please select one of the following options. *

I agree with the above recommendations. I commit to bringing my pet for regular examinations, listen to the doctors recommendations, ask questions as I need to, and work as a team with the staff at HPVC to create the best plan for my pet and family.

I have some questions about these recommendations and would like to be contacted by a member of the HPVC team. Together we will determine if this type of veterinary care is appropriate for my pet.

I only want basic veterinary care for my pet.

OtherOther

Signature *

Clear

Current Date *

Photo/Name Release: Healing Paws likes to use images of our client’s pets to demonstrate the care and attention that they receive here. When pets are happy and calm during treatment and care, it helps other pet owners to see how enjoyable veterinary care can be. Healing Paws will never share images of pets during the last moments of their lives, and we use discretion in the images taken and shared. We only use pet names and not owner names in our content. By signing below, I hereby give Healing Paws the right to use the name, video, and photographs of any of my pets in connection with its website and any promotional materials in any and all media, including, but not limited to, printed material, internet, social media, and film for display, public relations, and marketing. I hereby acknowledge receipt of adequate consideration and waive the right (i) to charge or be compensated for the use of the pictures, and my pet(s)’s name(s), and (ii) to inspect or approve the images prior to any form of usage. I understand that the images may be modified to use as design elements *

I have read, understand and give permission to the staff of Healing Paws Veterinary Care to use images of my pet/pets.

I do not give permission to the staff of Healing Paws Veterinary Care to use images of my pet/pets.

Professional fees are due in full at the time of services rendered.

Payment Options: Cash, checks drawn from a local bank, debit cards, VISA, MasterCard, and Scratch Pay only

Deposits: Non-refundable deposits are required for illness appointments, first new client visits, in-patient appointments, and anesthetic procedures.

Estimates: At your request, we will gladly discuss the cost of services and/or prepare a written estimate for recommended procedures and treatments. Our goal is to provide your pet with thorough care that also fits your family's needs. We believe in recommending the best for your pet and your family - if you desire an estimate, please request one before authorizing procedures being performed.

Cancelled Appts: We ask that if you must cancel or reschedule your appointment, you do so greater than 24 hours of your appointment (72 hrs for anesthesia appointments). With the exception of emergency, management deemed extenuating circumstances all appointments that are canceled or rescheduled within 24 hrs of the appointment time (72 hrs for anesthesia appointments) or are no shows will be assessed a cancellation fee. The cancellation fee must be paid in full before rescheduling the next appointment in these situations.

Returned Checks: We charge a $100 fee for returned checks. This returned check charge and the client balance must be paid in full before scheduling any further appointments.

Failure to Pay: In the event you refuse or otherwise fail to make payment owed for services rendered by us in caring for your pet, you are responsible for any and all costs of collection incurred by us, including attorney's fees, to collect payment(s) from you.

I have read, understand and agree to the above statement *

I acknowledge

I represent that any information I provided above is accurate and agree to the terms set forth herein. I understand that payment in full is due to Healing Paws Veterinary Care, Inc. (“Healing Paws”) at the time services are rendered. I authorize Healing Paws to collect payment if I do not pay in accordance with this agreement and agree that I am responsible for all costs of collection, including, but not limited to, attorney’s fees and court costs. I have been informed that estimates for recommended services/procedures are available upon my request. I further understand that all services performed on my pet will be invoiced according to Healing Paws procedures.

Please check below. *

I have read, understand, and agree to the above statement

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Medical Record Request Form

Medical Record Release

Releaser Section

Pet Owner Name *

Pet Owner Name

First

Last

Address *

Address

City

State

Zip

Phone *

Email *

Pet's Name *

Recipient Section

Name of Facility or Person to Whom We Have Permission To Release Records *

Email Address of Facility or Person to Whom We Have Permission To Release Records *

Phone Number of Facility or Person to Whom We Have Permission To Release Records *

Mailing Address of Facility or Person to Whom We Have Permission To Release Records *

Mailing Address of Facility or Person to Whom We Have Permission To Release Records

City

State

Zip

Please note: As fax machines are not always reliable, please note that we email or U.S. Postal Service mail medical records. If you would like the record faxed, you are welcome to pick up the written records (we will need 72 hours notice for this) and fax them from your home.

Time Period

What dates of your pet's care do you authorize the records to be released? *

My pet's entire record

Specific months of care

What are the specific months of records you authorize to be released? *

Record Types

Which specific record types would you like released? (choose all that apply) *

Vaccination Reminders/Due Dates

Laboratory Results

Prescriptions

Examination Notes

Diagnoses

Please note: We can not release records from other medical facilities, we can only release records of services and products provided by Healing Paws Veterinary Care, Inc.

What is the reason for this request? *

Boarding or daycare requirements

Grooming requirements

New pet adoption application

Moving out of the area

Discontinuing Veterinary Care Relationship with Healing Paws

OtherOther

Client feedback is important to us. Please briefly and respectfully share with us why you are transferring your pets' care to another facility. If you would like to discuss these reasons in person, please reach out to our client experience coordinator Jessica at jlambert@carlisleveterinarian.com! *

Expiration Date

In what time period from today's date do you want this record release to expire? *

30 days

60 days

90 days

6 months

12 months

I authorize that I am the legally responsible owner of the above named pet. *

I authorize

I authorize that I am over 18 years of age. *

I authorize

Signature *

Clear

Date *

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Prescription Refill Request Form

Refill Request Form

Pet Owner's Name *

Pet Owner's Name

First

Last

Phone Number *

Email *

We advise that you keep 2-4 weeks extra of food and prescriptions on hand at home as unexpected backorders or nationwide shipping issues can sometimes cause delays that lead to interruptions in your pet’s care.

How would you like to get your refill? *

Ship To My Home - Purina ProPlan

Ship To My Home - Medications, Supplements, Foods other than Purina

Pick Up Refill At Healing Paws

Pick Up Written Prescription To Use At Pharmacy of My Choice

No Preference

Click Here to Order Purina Products Shipped To Your Home Please use code 9HDXZ at check out.

Shop with Us

Patient Name *

List the first product you need refilled (one product only, you will have the ability to list others later in this form). *

How much are you giving your pet and how many times a day? *

We recommend always having 2-4 weeks extra of long term prescriptions on hand, how much of this product would you like to order? *

One-month supply (if available)

Three-month supply (if available)

Six-month supply (if available)

OtherOther

Do you need other products refilled for this pet? *

Yes

If others, please name the product/s in detail.

How much are you giving your pet and how many times a day? *

We recommend always having 2-4 weeks extra of long term prescriptions on hand, how much of this product would you like to order? *

One-month supply (if available)

Three-month supply (if available)

Six-month supply (if available)

OtherOther

How is your pet doing on these medications or food (same, better, worse, etc.)? *

Are you having any trouble getting your pet to take these medications or food? *

If so, our team will evaluate if there are better options to help make things easier.

Within what time frame will you run out of the food, medication, or product? *

Our doctor and staff that fills prescriptions is also the team that cares for patients and sees appointments, prescription refills, and written prescriptions have a five business day processing time. If you need your refill more urgently and have told us so above, we will do our best to meet your needs but may not be able to get the product for you earlier d ending on stock and staffing levels. Due to nationwide stocking shortages and shipping delays, we also recommend that you always keep 2-4 weeks extra of food and prescriptions on hand at your home. Thank you.

Please visit our Healing Paws Veterinary Care Online Store, which is linked directly to your pet's medical records, allowing us to ship products to your home straight from our distributor without the need for you to come to the clinic to pick up a written prescription. Our online store products allow you to support us as a locally owned small business, trust that the products you receive are accurate, and order easily at any time, day or night and because it goes straight to you from the distributor, the cost is less than picking up products at our clinic.

Most big box online pharmacies are now requiring "wet signature" written prescriptions. These prescriptions take five business days for us to process and require you to pick up the prescription in person from Healing Paws, and then you must post-mail the prescription to the online pharmacy you have chosen. Our Healing Paws Veterinary Care Online Store skips these steps completely. Please remember, if choosing an online pharmacy other than our direct distributor, you should always follow these FDA Choosing an Online Pharmacy Safety Recommendations.

Please choose one of the following options: *

I would like to quickly order now from the Healing Paws Veterinary Care Online Store

I have not used the Healing Paws Veterinary Care Online store before, I would like a team member to review the products I need and send me the online store link with a 10% coupon!

I have read the above and decline the 10% coupon. I understand the above and release Healing Paws Veterinary Care and its employees from any responsibility regarding the safety and accuracy of products I purchase for my pet through third party online pharmacies. I understand that a written prescription takes 5 business days to process and I am responsible for picking up that written prescription and submitting it to the pharmacy of my choice.

Click here to visit our online pharmacy!

Patient Name *

List the first product you need refilled (one product only, you will have the ability to list others later in this form). *

How much are you giving your pet and how many times a day? *

We recommend always having 2-4 weeks extra of long term prescriptions on hand, how much of this product would you like to order? *

One-month supply (if available)

Three-month supply (if available)

Six-month supply (if available)

OtherOther

Do you need other products refilled for this pet? *

Yes

If others, please name the product/s in detail. *

How much are you giving your pet and how many times a day? *

We recommend always having 2-4 weeks extra of long term prescriptions on hand, how much of this product would you like to order? *

One-month supply (if available)

Three-month supply (if available)

Six-month supply (if available)

OtherOther

How is your pet doing on these medications or food (same, better, worse, etc.)? *

Are you having any trouble getting your pet to take these medications or food? *

If so, our team will evaluate if there are better options to help make things easier.

Within what time frame will you run out of the food, medication, or product? *

Patient Name *

List the first product you need refilled (one product only, you will have the ability to list others later in this form). *

How much are you giving your pet and how many times a day? *

We recommend always having 2-4 weeks extra of long term prescriptions on hand, how much of this product would you like to order? *

One-month supply (if available)

Three-month supply (if available)

Six-month supply (if available)

OtherOther

Do you need other products refilled for this pet? *

Yes

If others, please name the product/s in detail. *

How much are you giving your pet and how many times a day? *

We recommend always having 2-4 weeks extra of long term prescriptions on hand, how much of this product would you like to order? *

One-month supply (if available)

Three-month supply (if available)

Six-month supply (if available)

OtherOther

How is your pet doing on these medications or food (same, better, worse, etc.)? *

Are you having any trouble getting your pet to take these medications or food? *

If so, our team will evaluate if there are better options to help make things easier.

Within what time frame will you run out of the food, medication, or product? *

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Cat Home Pain Assessment Form

Cat Pain Assessment Form

To learn if your kitty could be hiding chronic or acute pain, please check all boxes that apply (even if they only occasionally occur). Once submitted, this form will be reviewed and you will be contacted with the next steps in getting your kitty more comfortable!

Name *

Name

First

Last

Email *

Date *

Cat's Name *

Cat's Age *

Grooming/Hair Coat

Greasy, clumped, or dry hair coat

Dirty, long, thick or peeling toenails

Patches of hair loss

Licking, biting, or pulling hair out

Self-grooming less

Decreased use of scratching pads

Resents being touched or brushed in certain parts of the body

Activity

General activity seems decreased

Slowing down with age

Decreased interest in or less time spent playing

Decreased interaction with humans or other pets

Spends most of their time in one place in the house

Spends a large amount of time sleeping in a room away from family

Sudden episodes of meowing with no apparent reason

Sudden episodes of looking at part of body and then licking, pulling hair or biting the area

Sudden episodes of running away with no apparent reason

Growls or hisses when someone touches them

Cries out when moving or when touched

Movement

Movement seems stiffer and less fluid

Chooses to use chairs/stools etc to jump on or off high surfaces

Suddenly sitting down when walking, playing, or using stairs

Navigates stairs slowly

Asks to be picked up instead of jumping on your lap

Hesitates or takes several tries before jumping on a surface

Bunny hop using either both hind or both front legs together to go up or down stairs

Limping (any amount or severity)

Bodily Functions

Changes in food and water intake

Picky about food types

Misuse of litter box - urinating or defecating near but not in litter box at times

Has bowel movements less than once daily

Has hard, small, or dry bowel movements

Vomits more than once monthly

If you see a movement or change in your cat’s behavior that you are unsure about, please upload up to 3 videos here.

Maximum file size: 52.43MB

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Dog Home Pain Assessment Form

Dog Pain Assessment Form

To learn if your dog could be hiding chronic or acute pain, please check all boxes that apply (even if they only occasionally occur). Once submitted, this form will be reviewed and you will be contacted with the next steps in getting your friend more comfortable!

Name *

Name

First

Last

Email *

Date *

Dog's Name *

Dog's Age *

Grooming/Hair Coat

Swollen, red, or inflamed tissue on feet, legs or body

Patches of hair loss

Licking paws or elsewhere on the body

Biting self or pulling hair out

Resents being touched or brushed in certain parts of the body

Activity

General activity seems decreased

Slowing down with age

Decreased interest in or less time spent playing

Changes in interaction with humans or other pets

Spends most of their time in one place in the house

Spends a large amount of time sleeping in a room away from family

Chooses a cold hard floor to sleep on

No longer sleeps in human bed

Sudden episodes of growling with no apparent reason

Sudden episodes of looking at part of body and then licking, pulling hair or biting the area

Growls or snaps when someone touches them

Seems more irritable than in the past

Cries out when moving or when touched

Movement

Movement seems stiff

Suddenly sitting down when walking, playing, or using stairs

Runs or uses stairs with feet bounding together

Navigates stairs slowly

Asks to be picked up instead of jumping on your lap

Hesitates or takes several tries before jumping on a surface

Bunny hop using either both hind or both front legs together to go up or down stairs

Limping (any amount or severity)

Bodily Functions

Changes in food and water intake

Picky about food types

Bathroom accidents or “leaking”

Has bowel movements less than once daily

Has hard, small, or dry bowel movements

Vomits more than once monthly

If you see a movement or change in your dog’s behavior that you are unsure about, please upload up to 3 videos here.

Maximum file size: 52.43MB

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