New Client Form

Registration

Name of Owner *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Alternate Phone

Email *

Spouse/Partner

Phone

Email

Preferred Contact Method *

Phone
Email

How did you hear about us? *

Who referred you, we'd love to thank them!

If Other, please explain

Patient Information

Patient's Name (or list as herd, flock or appropriate group term) *

Species *

If Other, please elaborate

Age

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed

Colour *

List any known allergies

Other pets in the household? *

Yes
No

Would you like to add information for another pet? *

Yes
No

Patient's Name (or list as herd, flock or appropriate group term) *

Species *

If Other, please elaborate

Age

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed

Colour *

List any known allergies

Would you like to add information for another pet? *

Yes
No

Patient's Name (or list as herd, flock or appropriate group term) *

Species *

If Other, please elaborate

Age

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed

Colour *

List any known allergies

Please upload any of your pet's records that you may have

Click or drag files to this area to upload. You can upload up to 5 files.

Do you have pet insurance? *

Yes
No

If yes, please let us know which company

Former Veterinarian Name/Hospital

Former Veterinarian's Phone Number

Payment

We are happy to provide care for your animal and will review all estimated costs before proceeding with any treatment or procedure as part of our informed consent process. *

I have read and understand

Payment is accepted at the time of service unless otherwise pre-authorized through our Clinic Manager. *

I have read and understand

Please indicate your preferred payment method *

Signature of Pet Owner *

Clear Signature

Date *

We are now accepting deposits to secure appointments. Please call us to book your spot.

Registration

Patient Information

Payment