Kennedy Heights - 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 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 our deposit policies:

A deposit (amount of the examination fee) is required for all New Patient and Exotic animal appointments, in order to secure the appointment time. The deposit is refundable as long as a minimum of 24 hour notice is provided to cancel or change the appointment.

For Surgeries, we require a deposit of 50% of the estimated cost in order to secure the surgery appointment. This deposit must be paid at least 48 hours prior to the scheduled surgery.

Name (Primary Owner)*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Day-Time Phone*

Please enter a valid phone number.

Evening Phone

Please enter a valid phone number.

Mobile Phone

Please enter a valid phone number.

Email*

example@example.com

Co-Owner Name

First NameLast Name

Co-Owner Phone

Please enter a valid phone number.

How did you hear about us?

Please use this area to give us any other relevant information about yourself or your family:

Pet's Name*

Species*

What species is your pet?

Breed

Colour

Date of Birth / Age

Sex

Special Identification

i.e. Tattoo, Microchip, etc.

Name of Previous Veterinary Practice

Name of Previous Veterinarian

Date of Last Vaccines (if known)

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 list the allergies and reactions:

Are there any current or past medical conditions of which we should be aware?

YesNo

Please comment on the condition(s) and indicate if they are current or past conditions:

Please use the following box to give us any other relevant information about your pet:

CAPTCHA*

CLIENT INFORMATION

PET INFORMATION