New Client Form in El Dorado, KS

Complete the New Client Form before your first visit to Bluestem Animal Clinic in El Dorado, Kansas. Submitting this form ahead of time helps our team prepare for your pet’s appointment, review important details accurately, and make check-in easier for new clients and their dogs or cats.

Complete Form Request Appointment

New Client Form

Please complete this form before your first appointment with Bluestem Animal Clinic. Providing your contact information and your pet’s history in advance helps our El Dorado team prepare for a smoother, more organized visit.

Title

Dr.
Mr.
Mrs.
Ms.
Miss

First Name *

Last Name *

Spouse / Significant Other

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Phone *

Work Phone

Spouse Phone

Preferred contact method

Primary Phone
Work Phone
Email
Permission to Contact Via Text/Email

How did you hear about us? Is there someone we may thank for your referral?

Pet Information

Pet’s Name *

Species *

Dog
Cat
Other

Sex *

Male
Female

Birthdate

Breed

Color

Neutered / Spayed

Age

List Any Allergies

Please check any symptoms that you may have noticed about your pet:

Bad Breath
Behavior Issues
Bleeding Gums
Breathing Problems
Coughing/Gagging
Vomiting
Diarrhea
Bulging or Bloodshot Eyes
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Shaking Head
Sneezing
Increased Thirst or Urination
Weakness
Weight Issues
Seems Depressed

Do you have a second pet?

Pet’s Name *

Species *

Dog
Cat
Other

Sex *

Male
Female

Birthdate

Breed

Color

Neutered / Spayed

Age

List Any Allergies

Please check any symptoms that you may have noticed about your pet:

Bad Breath
Behavior Issues
Bleeding Gums
Breathing Problems
Coughing/Gagging
Vomiting
Diarrhea
Bulging or Bloodshot Eyes
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Shaking Head
Sneezing
Increased Thirst or Urination
Weakness
Weight Issues
Seems Depressed

Do you have a third pet?

Pet’s Name *

Species *

Dog
Cat
Other

Sex *

Male
Female

Birthdate

Breed

Color

Neutered / Spayed

Age

List Any Allergies

Please check any symptoms that you may have noticed about your pet:

Bad Breath
Behavior Issues
Bleeding Gums
Breathing Problems
Coughing/Gagging
Vomiting
Diarrhea
Bulging or Bloodshot Eyes
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Shaking Head
Sneezing
Increased Thirst or Urination
Weakness
Weight Issues
Seems Depressed

Do you have a fourth pet?

Pet’s Name *

Species *

Dog
Cat
Other

Sex *

Male
Female

Birthdate

Breed

Color

Neutered / Spayed

Age

List Any Allergies

Please check any symptoms that you may have noticed about your pet:

Bad Breath
Behavior Issues
Bleeding Gums
Breathing Problems
Coughing/Gagging
Vomiting
Diarrhea
Bulging or Bloodshot Eyes
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Shaking Head
Sneezing
Increased Thirst or Urination
Weakness
Weight Issues
Seems Depressed

Do you have a fifth pet?

Pet’s Name *

Species *

Dog
Cat
Other

Sex *

Male
Female

Birthdate

Breed

Color

Neutered / Spayed

Age

List Any Allergies

Please check any symptoms that you may have noticed about your pet:

Bad Breath
Behavior Issues
Bleeding Gums
Breathing Problems
Coughing/Gagging
Vomiting
Diarrhea
Bulging or Bloodshot Eyes
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Shaking Head
Sneezing
Increased Thirst or Urination
Weakness
Weight Issues
Seems Depressed

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid for by the date of release, and that a deposit may be required for surgical treatment or hospitalization. *

I have read and agree

Name *

Signature *

Clear Signature

Date *

**PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED**

We accept cash, checks, Visa, MasterCard, Discover, American Express and CareCredit.

Phone

Request Your Pet’s Visit

Bluestem Animal Clinic provides full-service veterinary care for dogs, cats, and select pocket pets in El Dorado, KS, serving families from Augusta, Towanda, Benton, Leon, and communities across Butler County. From wellness visits and diagnostics to surgery, urgent care, and boarding, our team is here to help. Ready to schedule? Request an appointment today.

Request Appointment

Have A Question?

Need to reach our team? Contact Bluestem Animal Clinic for appointments, boarding questions, prescription support, or general veterinary care information. We are here to help pet owners in El Dorado and surrounding communities.

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Location

830 W 6th Ave
El Dorado, KS 67042

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Contact Information

Phone: (316) 321-0811
Fax: (316) 321-3846
Email: frontdesk@bluestemvet.com

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Hours

Monday-Friday: 8:00 AM – 5:30 PM
Saturday: 8:00 AM – 12:00 PM
Sunday: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Name