West Brant Animal Hospital - Patient/ Client Intake Form

Patient/ Client Intake Form

Welcome to West Brant Animal Hospital. Thank you for giving us the opportunity to care for your pet. Please help us to meet your needs better by taking a moment to complete this information sheet.
Client Information
Primary Owner*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email*
example@example.com
How would you like to be contacted?(select more than one if you prefer multiple points of contact)*

Phone CallText MessageEmail
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Drivers License *
Are you over 65 years old?

YesNo
Do you have a status card?

YesNo
If yes, please bring your status card to your first appointment so we can take a photocopy for our records. Thank you.
Please provide your status number here:
How did you first hear about us?
Driving by, Yellow Pages, Social Media, Family/ Friend
We understand that you may not always be available to bring your pet to the clinic. Please let us know who else may be bringing them:
Owner #2

First NameLast Name
Phone Number
Please enter a valid phone number.
Do they have permission to make medical decisions?

YesNo
Owner #3

First NameLast Name
Phone Number
Please enter a valid phone number.
Do they have permission to make medical decisions?

YesNo
Please confirm all Owner(s) listed above are over 18 years of age*

Owner(s) listed above are over 18 years of age
Pet's Information
Pet's Name*
Date of Birth or Age*
Species*

CanineFeline
Sex*
Breed*
Colour*
Microchip Number
Do you have any concerns with your pet currently? Please provide details.*
Please list previous vet clinic(s):*
Do you give us consent to request your pet's previous medical history?*

Yes, I consentNo, I do not consent
Any previous vaccines or medication reactions?*

YesNo
If yes, please explain in detail what happened:*
How can we keep your pet comfortable at their appointment?*
eg. loves treats, room with no windows, afraid of the scale, does better away from owner, doesn't like lab coats
What does your pet require for appointments?*
eg. needs a muzzle, cannot be around other dogs, requires anxiety medications prior to visit
Any history of seizures/collapse?*

YesNo
If yes, please explain in detail what happened and if your pet is on any treatment:*
Any Diet Restrictions?*
I have another pet to provide info for
Pet #2
Pet's Name*
Date of Birth or Age*
Species*

CanineFeline
Sex*
Breed*
Colour*
Microchip Number
Do you have any concerns with your pet currently? Please provide details.*
Please list previous vet clinic(s):*
Do you give us consent to request your pet's previous medical history?*

Yes, I consentNo, I do not consent
Any previous vaccines or medication reactions?*

YesNo
If yes, please explain in detail what happened:
How can we keep your pet comfortable at their appointment?*
eg. loves treats, room with no windows, afraid of the scale, does better away from owner, doesn't like lab coats
What does your pet require for appointments?*
eg. needs a muzzle, cannot be around other dogs, requires anxiety medications prior to visit
Any history of seizures/collapse?*

YesNo
If yes, please explain in detail what happened and if your pet is on any treatment:
Diet Restrictions?*
I have another pet to provide info for
Pet #3
Pet's Name*
Date of Birth or Age*
Species*

CanineFeline
Sex*
Breed*
Colour*
Microchip Number
Do you have any concerns with your pet currently? Please provide details.*
Please list previous vet clinic(s):*
Do you give us consent to request your pet's previous medical history?*

Yes, I consentNo, I do not consent
Any previous vaccines or medication reactions?*

YesNo
If yes, please explain in detail what happened:
How can we keep your pet comfortable at their appointment?*
eg. loves treats, room with no windows, afraid of the scale, does better away from owner, doesn't like lab coats
What does your pet require for appointments?*
eg. needs a muzzle, cannot be around other dogs, requires anxiety medications prior to visit
Any history of seizures/collapse?*

YesNo
If yes, please explain in detail what happened and if your pet is on any treatment:
Diet Restrictions?
ALL APPOINTMENTS ARE TO BE PAID FOR AT THE TIME OF THE VISIT.

NEW CLIENTS: A DEPOSIT WILL BE REQUIRED AT THE TIME OF BOOKING.

We accept Debit, Visa, MasterCard, Cash and E-Transfer
Should be Empty:

Patient/ Client Intake Form

Client Information

Pet's Information

Pet #2

Pet #3