New Client Form

New Client Form

Thank you for entrusting us with your pet's care. Please fill out our New Client form and a staff member will contact you within two business days. If this is an emergency, please contact us at 613-392-8900. If this is outside of our regular business hours, please contact Quinte Regional Pet Hospital at 613-968-9956.
Owner Information
Owner's Name*

First NameLast Name
Phone Number*
Co-Owner

First NameLast Name
Work Phone Number
Cellular Phone number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Informed Consent for Email Contact:

By providing my email address below, I am agreeing that Quinte Animal Hospital employees are permitted to send emails to the below address in regards to my pets.

I can opt out of receiving emails at any time by contacting the hospital by phone or email. This email address may be used in correspondence relating to pet health insurance, news, updates etc.
Email*
example@example.com
Would you like access to our web store?*
Are you a member of the Canadian Armed Forces?*
Valid ID will be required for military discount
How Did You Find Out About Our Hospital?*
Please enter their name so we can send a "Thank you"
Which site?
Please specify
What Will Our Relationship Be?*
If other
Emergency Contact
Name*

First NameLast Name
Phone Number*
Patient Information
Pet's Type*

DogCat
Pet Name
Breed
Gender
Spayed / Neutered?
Colour
Age / Date of Birth

MonthDayYear
Would you like to add another pet?*

YesNo
Pet's Type

DogCat
Pet Name
Breed
Gender
Spayed / Neutered?
Colour
Age / Date of Birth

MonthDayYear
This information is obtained in confidence and is intended for use only by Quinte Animal Hospital. Any other distribution, copying or disclosure is strictly prohibited. The contents of this document may also be subject to privilege and all rights to that privilege are expressly claimed and not waived.
Photo Release
We want to make your pet famous! Do we have your permission to share your pet's photo and/or story online? Images may also be used for educational or advertising purposes.*

YesNo
Upload here

Cancelof
By submitting this New Clients Form, I agree that I am the legal owner of the pet(s) listed above and that all information is true.
Should be Empty:

New Client Form

Owner Information

Emergency Contact

Patient Information

Photo Release