Parkwest Pet Clinic - New Client Form

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 to help expedite the registration process and give us valuable insight into providing optimal care for your pet(s). All required sections have a red *asterisk.
OWNER INFORMATION
Owner's Name *

First Name Last Name
Address *

Street Address

Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Cell Phone *
Name of cell phone carrier *
Home Phone
Work Phone
Preferred Contact Method *

Email Cell Phone Home Phone Work Phone
Do you consent to Parkwest Pet Clinic can contact you by e-mail or SMS text message for the purpose of medical care for your pet(s)? *

Yes No
Do you give Parkwest Pet Clinic permission to take photos of your pet(s) to post on the clinic's social media pages? *

Yes No
CO-OWNER INFORMATION
Co-Owner/ Emergency Contact

First Name Last Name
Co-Owner Phone
Relationship to Owner
i.e. pet parent, partner, friend, etc.
Add another co-owner/emergency contact?

Yes No
Co-Owner/ Emergency Contact

First Name Last Name
Co-Owner Phone
Relationship to Owner
i.e. pet parent, partner, friend, etc.
PET INFORMATION
Pet Information *

Name Species
*

Breed (if known) Colour
*

Age Gender
Sex *
Does your pet have a microchip/tattoo?
If yes, please enter the microchip# or tattoo details.
Yes or No *

Spay or Neutered? Identification (e.g. tattoo or microchip)
Does your pet have insurance? *

Yes No
Please provide the policy number and name of insurance provider: *
Medication/ Supplements:
Please note, an exam is required for any refill of medication for new clients/patients.
Name and phone number of previous veterinary care provider:
Would you like to add another pet?

Yes No
Pet Information *

Name Species
*

Breed (if known) Colour
*

Age Gender
Sex *
Does your pet have a microchip/tattoo?
If yes, please enter the microchip# or tattoo details.
Yes or No *

Spay or Neutered? Identification (e.g. tattoo or microchip)
Does your pet have insurance? *

Yes No
Please provide the policy number and name of insurance provider: *
Medication/ Supplements:
Please note, an exam is required for any refill of medication for new clients/patients.
Name and phone number of previous veterinary care provider:
Additional Comments:
Should be Empty:

New Client Registration Form

OWNER INFORMATION

CO-OWNER INFORMATION

PET INFORMATION