New Patient Form

CLIENT INFORMATION

Please Select: *

New Client
Current Client - New Pet

Owner's Name *

Email *

We will only use your e-mail address to send out vaccination reminders.

Address *

City *

Province *

Postal Code *

Home Phone

Cell Phone *

CO-OWNER INFORMATION

Co-Owner's Name

Address

City

Province

Postal Code

Phone

Cell

PET(S) INFORMATION

Tell us about your pet(s): *

	Pet Name	Breed	Colour	DOB/Age	Sex	Primary Clinic	Doctor
1.
2.
3.
4.
5.

Does your pet have any major ongoing medical conditions we should know about? Please List.

Do your pets travel out of the area? Please List.

Do you have pet insurance? *

Yes
No

Please note: If you have insurance, we will need to set up a master claim form with your signature to keep on file.

All professional fees are due at the time services are rendered. Please ask for an estimate prior to any extensive medical or surgical procedure – we will be happy to provide one. We accept Cash, Interact, VISA, and Mastercard. We DO NOT accept American Express or Personal Cheques.

Signature *

Date

Today

CAPTCHA *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *