New Customer Registration Form

New Client Registration Form

Harbour Cities Veterinary Hospital
Client Name/Owner*

First NameLast Name
Secondary Name/Owner
Full Name
I acknowledge
Initials*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Home Contact NumberFormat: (000) 000-0000.
Cellular Contact NumberFormat: (000) 000-0000.
Secondary Phone Number
Secondary Contact NumberFormat: (000) 000-0000.
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*
Breed*
Date of Birth/ Estimate of Age*
Ex. mm/dd/yyyy or 12 years
Coat Colour
Previous Vet Hospitals Visited (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
Breed
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 veterinarian 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?
Yes, I have read and understand the 'Code of Conduct'
Yes, I have read and understand the 'Payment Policy'
Please verify that you are human*
Signature
Should be Empty:

New Client Registration Form

Patient Information: