ONLINE SERVICES    

Online
Consultation




Medication
Refills



New Patient
Registration



Vet Referral
Form Online



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  Sick pets are our specialty

Tidewater Veterinary Internal Medicine
Virginia Beach Veterinary Specialist Care for pets in eastern Virginia Virginia Beach

Keith A. Kremer, DVM, DACVIM
Board-certified Specialist in small animal Internal Medicine

(757) 605-1610 clinic@specialistvet.com

Welcome to Our Site

Go Green!  New Client Registration Online

You may now complete your check-in forms online before your appointment.  Please note this form is to be used for an actual appointment - if you are requesting an online consultation, please complete the "online consultation" form on another page.  We encourage you to use this form for several reasons, including faster check-in, more thorough referral information regarding your pet's problems, legibility of information, and of course to help conserve paper and ink.  At this time, we are not scheduling appointments online, so you will need to call us to schedule your appointment.  You can call us between 8am and 4:30 pm on M, T, Th and F  to schedule your appointment.  Our phone number is (757) 605-1610. 
Thank you, and we look forward to seeing you and your pet!

Form - New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Preferred phone # (required)
Phone TypePhone Number (required)
Alternate phone # (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :
Breed: (required)

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed

Please check any vaccines below that are overdue for your pet. (required)
All vaccines current
Rabies
Parvovirus
Canine distemper
Bordetella
Feline distemper / upper respiratory
Feline leukemia
Name of Regular Vet (required)

Name of Regular Vet Hospital (required)

How did you find us? (required)
My vet
Friend
Family
Internet
Other

May we thank someone for referring you to us? Please list name.

Do you have any comments or suggestions for our website content?

Yes, include me on your email list for pet health news, patient progress reports, and reminders?
Your pet's diet, including treats. Please be specific, ie brand, canned vs. dry (required)

Food or drug allergies? Please list.

Has your pet been previously diagnosed with any of the following conditions?
allergies
arthritis
dental disease
heart murmur
asthma
recurrent bladder infections
seizures
high blood pressure
tumor
no previous problems
other (list below)
Please explain any previous problems listed above if needed.

Has your pet ever had cancer or a tumor? If yes, please list type, location, date and any treatment

Please check any of the following symptoms your pet is having. (required)
weight loss
decreased appetite
increased appetite
increased thirst
increased urination
lethargy/weakness
vomiting
diarrhea
blood in stools
black stools
mucus in stools
increased frequency of bowel movements
straining to defecate
straining to urinate
blood in urine
leaking urine during rest
fluid in abdomen
fluid retention/edema
coughing
labored breathing
fluid in chest
lumps or growths
pale gums
jaundice (yellow)
seizures
loss of vision
limping
signs are constant
signs are episodic
none applicable
If your pet has lost weight, how much weight has it lost and over what time frame?

When did your pet's problems begin? List date. (required)

Is your pet's problem (required)
getting worse
getting better
about the same
Please briefly describe your pet's problems. (required)

Please list all current medications your pet is receiving. (required)

Has any treatment been effective for your pet's problems? Please explain.

Please Read
I understand that I am responsible for any charges incurred by my pet while under the care of Dr. Kremer, and that charges are due and payable at the time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5%, or 18% per annum. I hereby grant authority to Dr. Kremer & his staff to administer tests and treatment as deemed necessary or advisable in my pet's care. I understand and agree to the following: A 5% processing fee applies to all payments made using Care Credit; A $25 fee applies to all returned checks; Dr. Kremer is not responsible for interpretation of any future test results performed at other veterinary clinics; Medication refills require at least 24 hours notice; and I cannot accompany my pet for tests and procedures, including ultrasound exams, due to liability concerns and space constraints.
I have read this statement and - (required)
I Agree
I Disagree

Signature (required)
First Name (required)
Last Name (required)

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