New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight into providing optimal care for your pet(s). The required sections have a red * asterisk.

Once you have completed the registration process and would like to book an appointment, please see our “Make an Appointment” form or give us a call at 519-672-1210.

Owner's Name *

First

Last

Co-owner's Name *

First

Last

Email *

Day-Time Phone *

Evening Phone

Mobile Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Pet's Name *

Species

If Other, please specify:

Breed (if known) *

Color *

Date of Birth or Age (if known) *

Special Identification (tattoo, microchip, etc.)

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

What vaccines were given at this time?

Is your pet on any medication or supplement?

If Yes, please list the medication or supplement:

What food does your pet eat?

Does your pet have allergies or drug reactions? If Yes, please list the allergies and reactions.

Are there any current or past medical conditions of which we should be aware?

If Yes, please comment on the condition(s) and indicate if they are current or past conditions:

Please use the following box to give us any other relevant information about your pet: