SAI Veterinary Hospital - New Client Form
Welcome to SAI Veterinary Hospital (Small Animal General Practice & 24/7 Emergency After-Hours). To ensure the best possible care, please complete all sections within this form. As soon as you submit this online form, it will be sent directly to our reception and triage nursing team within a couple of minutes. If you wish to add additional animals to this form, please verbally advise our reception and triage nursing team. If you have any questions, please don't hesitate to ask the triage nurse on duty. Thank you for entrusting your pet/s into our care.
New Client Details
Please complete the below in full
New Client Name
*
Please Select
Mr
Mrs
Miss
Ms
Dr
Prof
Title
First Name
Last Name
Residential Address
*
Street Address
Suburb
City
State
Post Code
Contact Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
Email Address
*
example@gmail.com
Secondary Contact Details
Please complete all relevant information below
Secondary Contact Details
*
Please Select
Mr
Mrs
Miss
Ms
Dr
Prof
Title
First Name
Last Name
Relationship of Secondary Contact to you?
*
Please Select
Spouse
Friend
Relative
Other
Secondary Contact Email Address
*
example@gmail.com
Secondary Contact Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
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Next
New Animal Details
Please complete all relevant details regarding your animal below
Animal Name
*
Species
*
Please Select
Dog
Cat
Bird
Rabbit
Guinea Pig
Please select one of the options above
Breed
*
Colour
*
Age (Months or Years)
*
Sex
*
Please Select
Male
Female
Please select one of the options above
Desexed
*
Please Select
Yes
No
Please select one of the options above
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Reason for Visit (Please be detailed as possible)?
*
Does your pet have any known medical conditions, illnesses or diseases?
*
Is your pet up to date with vaccinations?
*
Yes
No
Unsure
Approximate date of last vaccination
*
Does your pet have any known behavioural issues or concerns? E.g aggression, fear reactions, resource guarding, generalised anxiety etc. If yes, please elaborate below
*
Does your pet have any known allergies to food, medication or environment?
*
Has your pet undergone any recent surgeries or veterinary visits? If yes, please explain and elaborate below
*
Is your pet currently on any medication/s? If yes, please list the below medication/s for the attending veterinarian's knowledge
*
PLEASE NOTE: EMERGENCY INFORMATION ONLY (PLEASE ENTER "N/A" IF NOT APPLICABLE) - Has your pet/s been exposed to any toxins, substances or medications? E.g. poisons, insecticides, human medication, substances, recreational drugs etc.
*
In the event of your pet experiencing a life-threatening emergency, would you like us to commence cardiopulmonary resuscitation (CPR) and advanced life support? (Costs for initial emergency stabilisation, IV catheterisation, oxygen therapy, cardiopulmonary resuscitation, basic blood panel, emergency medications and initial critical care is approximately between $500.00 to $700.00). Please select either YES or NO below.
*
Please Select
Resuscitate (Yes)
Do Not Resuscitate (No)
Is your pet insured?
*
Yes
No
Unsure
If your pet is insured, what insurance company is your pet insured with?
If your pet is insured, what is the insurance policy number?
Regular Veterinary Practice Details (if applicable)
I request that my pets history is sent back to my Regular Veterinary Practice mentioned above.
*
Yes
No
SAI Vet is/ is now my Regular Veterinary Practice
Do you give SAI Veterinary Hospital permission to use photos or videos of your pet for the purpose of our social media platforms (Facebook & Instagram)?
*
Please Select
Yes
No
How did you hear about us?
*
Please Select
Referred by another vet
Word of mouth
Google search
Facebook
Curtain radio
Drive-by
Financial Agreement and Legal Authorisation
Please ensure you read, understand and acknowledge the below
I hereby declare that I am 18-years of age or older and authorise the duty veterinarian of SAI Veterinary Hospital to examine, prescribe, and appropriately treat my animal/s. I assume responsibility for all charges incurred in the care of my animal/s. I understand and acknowledge that payment is due at the time of service. I have read, understood and agreed to this policy and accept full responsibility for all incurred fees. I understand if I fail to pay as agreed, legal action may be commenced against me and possible legal proceedings may commence. I agree to pay any costs incurred in the legal process including but not limited to late financial and account charges, legal fees and general collection agency fees.
*
Please Select
I have read, understood and acknowledged the above hospital policy
Please select the drop-down option above
Signature of Person Responsible
*
Submit
Submit
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