Leaside AC - New Client Registration 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 prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Please note: We are booking approximately 3 weeks out for yearly appointments. Please call for all urgent appointments. Reply to this form may take up to 48 hours for a call back.
OWNER'S NAME
Name*

First NameLast Name
Please select your prefix/pronouns (select all that apply):

Mr.Mrs.Ms.Mx.Dr.He/HimShe/HerThey/ThemOther
CO-OWNER'S NAME & CONTACT #
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
ADDRESS
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
How did you find out about our practice?

Clinic LocationPersonal ReferralInternet Search / WebsiteYellow PagesClinic SignNewspaper / Print MediaOther
Is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family:
PET INFORMATION
Pet's Name*
Species*
Or, if other species:
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)

MonthDayYear
Date
What vaccines were given at this time?
Is your pet on any medication or supplement?

YesNo
Please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?

YesNo
Please comment on the condition(s) and indicate if they are current or past conditions
Please provide us any other relevant information about your pet
Would you like us to get your previous vet records?

YesNo
Would you like us to call you to set up an appointment?

YesNo
Consent

I give permission for Leaside Animal Clinic to use pictures of my pet for social media purposes.
CAPTCHA*
Should be Empty:

OWNER'S NAME

CO-OWNER'S NAME & CONTACT #

ADDRESS

PET INFORMATION