Brookfield Veterinary Hospital Intake Form

Patient Intake Form

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

YesNo
Owner's Name*

First NameLast Name
E-mail*
Main Contact Number:*

Area CodePhone Number
Address - please update information if anything has changed since your last visit:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
We love social media! Do we have permission to share your pet(s)' image and story on social media, our website and 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.

TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Brookfield Veterinary Hospital to examine, prescribe for or treat the my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the except of another veterinary facility.
Clear
Should be Empty:

Patient Intake Form