New Customer Registration Form

New Client Registration Form

Harbour Cities Veterinary Hospital
Client Name/Owner *

First Name Last Name
Secondary Name/Owner
Full Name
*** Please acknowledge only the above name(s) will be permitted to access patient information, make decisions regarding your pet's care, and discuss your pet(s) with our team. We strictly adhere to client/patient confidentiality and will not discuss anything pertaining to our patients with those not on file.*** *

I acknowledge
Initials *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Home Contact Number
Cellular Contact Number
Secondary Phone Number
Secondary Contact Number
E-mail *
example@example.com
Do you give express consent for us to contact you with appointment reminders and recent updates via email? *
Do you give express consent for us to contact you with photo updates of your pet while in hospital and use in social media? *
Patient Information:

Please include all pets in the household
Name *
Pets Name
Gender *
Species *
Date of Birth/ Estimate of Age *
Ex. mm/dd/yyyy or 12 years
Coat Colour
Referring Veterinarian (If Applicable):
Please forward all previous veterinary records to info@harbourcitiesvet.ca prior to your pet's appointment.
Is your pet on any continuous medications/supplements? This includes parasite prevention.
Tell us a little about your pets everyday life
Any medical/health concerns you would like us to make a note of?
Do you live in a multi-pet household? *
If you answered 'Yes' please fill out information below for each pet
PET # 2 Name:
Pets Name
Gender
Species
Date of Birth/ Estimate of Age
Ex. mm/dd/yyyy or 12 years
Coat Colour
Is your pet on any continuous medications?
Referring Veterinarian (If Applicable):
Please forward all previous veterinary records to info@harbourcitiesvet.ca prior to your appointment to allow the vertinarian ample time to review your pets medical history.
Tell us a little about your pets everyday life
Any medical/health concerns you would like us to make a note of?
CODE OF CONDUCT: Our team members are here because they want to help you with your furry friends. To best support them in this, it is imperative that all communications are respectful in nature. Obscene, abusive, or rude behavior towards any member of our team, or another client, is not acceptable. We reserve the right to discontinue services to anyone who exhibits behavior of this nature. *

Yes, I have read and understand the 'Code of Conduct'
PAYMENT POLICY: Payment is due at the time services are rendered. Acceptable payment methods include cash, debit, Mastercard, Visa and e-transfer. Harbour Cities Veterinary Hospital does not bill for services. If you have payment concerns - please speak to a member of the reception team about third-party payment options prior to your pet receiving care. *

Yes, I have read and understand the 'Payment Policy'
Please verify that you are human *
Signature

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New Client Registration Form

Patient Information: