New Customer Registration Form

New Client Registration

Thank you for considering Brookfield Veterinary Hospital for your pet's needs. Please fill out our new client/patient registration form in entirety to ensure we can provide you and your pet with the best possible care.
Have you every brought a pet to Brookfield Veterinary Hospital before?*

YesNo
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Contact Number:*

Area CodePhone Number
Secondary Contact Number:

Area CodePhone Number
E-mail*
Is there a Spouse/Partner/*

YesNo
Spouse/Partner/Family Member Name:

First NameLast Name
Please tell us how the above person is related to you:
Spouse/Partner/Family Member Contact Number:

Area CodePhone Number
How did you hear about us?*

Google (or other search engine)Facebookwww.redmondvet.comLocal businessSaw our hospitalA BVH team memberIs there someone we can personally thank for the referral?
Please list name(s):*
Pet's Name*
Species:*

DogCat
Date of Birth/Age of Your Pet:*
Sex*

MaleFemale
What Breed is your pet:*
What Color is your pet:*
Is your pet spayed/neutered:*

YesNo
Is your pet microchipped:*

YesNoI'm not sure
Previous Veterinarian(s)*
Upload Previous Veterinary Records

Browse Files
Please upload if available Cancelof
We love social media! Do we have permission to share your pet(s)' image & story on social media, our website & other forms of related media? We will not share personal information. Simply check below to authorize:*

Yes, I authorize BVH to share my pet's photo.No, I do not authorize BVH to share my pet's photo.
I have read and consent to the following:*

I understand that payment is due at the time of service.I understand 24 hour notice is required to cancel my appointment or the full cost of the exam will be charged.
Should be Empty:

New Client Registration