New Client Enrolment form

Villlage of Manotick Animal Hospital

Nepean-Rideau Veterinary Professional Corporation

5547 Scharfield Rd

PO Box 1070

Mantotick, ON K4M 1A9

(613) 692-2434

Welcome to Village of Manotick Animal Hospital!

Thank you for choosing us for your pet's vererinary care. We are dedicated to providing copasisonate, high-quality medicine tailored to your pet's needs. We are proudly able to accept new clients and patients at this time. To help us prepare for your appointment and ensure the best use of our time together, please complete and submit this intake form with a as much detail as possible. If previous medical records are not yet available, this information will assit our team in understnading your pet's health history and current needs. Our reception staff will be in touch about booking an appointment. Thank you for your interest in joining the Village of Manotick Animal Hospital family.

Client name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

I verify that I am the owner/acting guardian of the animal(s) described below. I assume responsibility for this animal, and I have the authority to execute consent. I also acknowledge that I am responsible for all charges incurred during my pet’s visit*

I confirm

Do you have a preferred veterinarian at our clinic?

If you were referred by someone, what is their name?

Reason for transfer*

New puppy or kittenNew to areaOther

Pet #1 information: name*

Pet's Date of Birth*

Species*

Breed*

Colour*

Pet's sex*

MaleMale/neuteredFemaleFemale/spayed

Pet #2 information: name

Pet's Date of Birth

Species

Breed

Colour

Pet's sex

MaleMale/neuteredFemaleFemale/spayed

Pet #3 information: name

Pet's Date of Birth

Species

Breed

Colour

Pet's sex

MaleMale/neuteredFemaleFemale/spayed

Do you already have a primary care veterinarian elsewhere?*

NoYes - Please indicate the contact information below:

If you need a file transferred from another clinic, what is the name and phone number or email of the veterinary clinic (or state none)?*

Reason for the appointment visit (annual, medical, etc)?*

Please list any recent changes such as appetite, weight, drinking habits, energy levels, vomiting, diarrhea, coughing, sneezing, mobitily issues, skin or coate condition.*

Please indicate your pet’s life style and behaviour (indoor, outdoor, both, rural, urban, hunting, etc).*

Please list any recent travel particularly out of province or country.*

Please list any behavioural concerns such as anxiety, aggression, fear of vet visits, inappropriate urination, etc.*

Please indicate any known allergies (food, medication, vaccines, environmental, etc).*

Please indicate the last known vaccine dates including dhpp, leptospirosis, lyme, bordetella and rabies (dogs) or fvrcp, felv, and rabies (cats).*

Please indicate any parasite prevention being used (brand, frequency, and date last given)*

Please list any previous serious illnesses, injuries, or surgeries)*

Please list any chronic medical conditions (ie diabetes, kidney disease, heart disease, allergies, etc)*

Please indicate current medications, supplements, or special diets (name, dose and frequency)*

Thank you for taking the time to complete this form. Please allow 2-3 business days for your application to be processed. A staff member will reach out to you directly to confirm enrolment. Please be advised that we are accepting new clients while spots are available and submitting this form does not guarantee enrolment with the clinic.Thank you for your interest in joining the Village of Manotick Animal Hospital family.

Please verify that you are human*