Client & Patient Initial Registration and Patient History Form

Walk In Clinic For Animals New Patient Registration Form
*IF YOU HAVE VISITED THE WALK IN CLINIC FOR ANIMALS BEFORE, PLEASE LET OUR STAFF KNOW*
Today's date

DayMonthYear
Date
Current Time

Hour Minutes

AM/PM Option
(If still en route, please advise of your ETA)

Hour Minutes

AM/PM Option
Pet Owner Details
Owner's Full Legal Name*

PrefixFirst NameLast Name
Owner/Client's Preferred Pronouns and/or Preferred Name, if applicable
Please specify any CLIENT-SPECIFIC details that you'd like to share that might improve your experience (for example - if you are hard of hearing, have any sensory sensitivities, needle-phobia, unable to hold/restrain your pet etc)
Preferred communication method for follow-ups*

Text messagePhone callDo not contact me for follow-up
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number (Primary)*
Secondary/Emergency Contact Name

Preferred pronounsFirst NameLast Name
Secondary/Emergency Phone Number
Which regular veterinary practice do you normally attend?*
Please write N/A if no regular vet
Who is your pet insurance provider? *
If you do not have pet insurance, please write N/A
If you do have pet insurance, please advise us of your policy number so that we can send the clinical records straight to your nominated insurance provider.
How did you hear about the Walk In Clinic For Animals? *
For example, from a friend, regular veterinarian, emergency clinic, Facebook, Google

Your Pet's Details
Your pet's name*
Your pet's weight today
Feline patients will be weighed in the consult room so this can be left blank for cats.
Species and Breed*
Colour*
Age or Date of Birth*
Sex*
Is this pet desexed?*

YesNo
Is there anything that we should be mindful of when handling your pet? (i.e. especially nervous, can't eat liver treats, history of biting or aggression, doesn't like feet being touched, head-shy, etc)*

Your Pet's Medical History
What has brought you in today? *
Does your pet have any relevant medical history? (Ongoing medical conditions, regular medications etc) *
Does this pet have any known allergies or reactions to any medications? If so, please provide information.*
Please note the date of this pet's last known vaccination booster*
Write N/A if unknown or not applicable
Does your pet regularly receive parasite prevention?*
Write N/A if unknown or not applicable
Please give an overview of your pet's current diet*
Dry food, wet food, brand or prescription if applicable, raw, cooked, supplemented, etc
Please list all other pets in your home and advise if they are also unwell.
Leave blank if no other pets at home
FELINE SPECIFIC - Does your cat have free access to the outdoors (ie. not in an enclosure)?
Leave blank if patient is not feline
Please describe any inciting event, even suspect, that may have triggered this illness or caused this injury.

Informed Consent for Consultation with Limited Scope of Practice

This notice is to advise you, our client, that the Walk In Clinic for Animals is not a full service veterinary hospital but rather an urgent care clinic. Our clinic operates under specific licensing conditions that legally limit our ability to provide major sugeries and other serious interventions.

As we are an urgent care clinic, we do not see patients in a regular capacity nor for chronic disease management, and for these services we will refer you to a general practice veterinary clinic. We do not perform major surgery, anaesthesia or hospitalization/management of critical or intensive-care patients. Patients requiring these services will be referred to an emergency hospital as soon as the pet is stable enough for transport. By proceeding with consultation, you accept the risk that we may not be able to resolve all of your pet's medical issues tonight and may need to refer you on to another service.

We recommend that all clients choose a general practice veterinary provider and maintain a relationship with them for the long-term health and wellbeing of their pet. In proceeding with consultation, you acknowledge this recommendation.

Our standard consultation fee is $220. Medication, procedures, pathology, and specialised examinations will be in addition to this fee.

In proceeding with consultation services here at the Walk In Clinic For Animals, you agree to pay your invoice in full at the end of your consultation. If you need to discuss payment services such as VetPay, please alert the front desk staff before starting your consultation.
Having read the above advice:*

I understand and agree to proceed with consultationI do not wish to proceed with consultation and will seek veterinary care elsewhere
I wish to receive a copy of this advice via email*

YesNo
Authority to Release for patient photographs to be used for social media and for inclusion to clinical notes to be forwarded to your regular vet, relevant allied health and/or referral facilities*

I give consentI wish to opt out
Should be Empty:

Walk In Clinic For Animals New Patient Registration Form

*IF YOU HAVE VISITED THE WALK IN CLINIC FOR ANIMALS BEFORE, PLEASE LET OUR STAFF KNOW*

Pet Owner Details

Your Pet's Details

Your Pet's Medical History

IF YOU HAVE VISITED THE WALK IN CLINIC FOR ANIMALS BEFORE, PLEASE LET OUR STAFF KNOW