Welcome to Central Langley Pet Hospital
"Caring for Pets and Their People'
Name
First Name
Last Name
Spouse (or anyone you share your pet with)
First Name
Last Name
Email
example@example.com
Cell Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
My preferred method(s) of contact are:
Email
Text
Call cell
Call home
Call work
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My pet is a:
Dog
Cat
Rabbit
Hamster
Guinea Pig
Gerbil
Rat
My pet's name is:
My pet's date of birth is:
-
Month
-
Day
Year
Date
My pet is a:
Female
Spayed Female
Male
Neutered Male
My pet's breed is:
My pet is ________ in colour:
Is your pet currently on any medication, flea or heartworm preventatives, supplements, or vitamins?
No
Yes (if yes, please list in the box below)
Are there any prior illnesses, injuries, or surgeries we should know about?
No
Yes (if yes, please describe in the box below)
Do you have any behavioural issues or concerns regarding your pet?
No
Yes (if yes, please describe in the box below)
Does your pet have any food allergies or sensitivities?
No
Yes (if yes, please list in the box below)
How did you hear about us?
Google
Petsmart Store
Petsmart Grooming
Social Media
Drove/Walked By
Referral (let us know who is the box below)
Please let us know who referred you so we can thank them!
Do we have your permission to obtain your pet's medical records?
Yes
No
Previous Veterinarian:
Signature:
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