Registration and First Appointment Request Form
Please fill out this form with your information and we will confirm we are able to accept your registration. If your request is urgent please email or call as well to ensure we have seen your message. NB. This is not an emergency service and if I am unable to attend you will have to be seen by a bricks and mortar practice in an emergency.
Your Details
*
First Name
Last Name
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Are there any issues with locating your property? Please leave any relevant info here if so:
Parking is:
Readily available, on street
Please park on the driveway
Parking is by visitor permit which we will provide
You will need to pay to park here (meter parking, multi-storey etc)
Other
What is the reason for your visit request?
Annual Vaccinations
Puppy/kitten vaccinations
Health Check
Poorly Pet Visit
Litter of puppies/kittens for 1st vaccinations and microchips
Quality of Life Assessment/Palliative Care
Pre-euthanasia Consultation (in person)
Pre-euthanasia Consultation (online)
Animal Health Certificate
I don't need a visit yet, I'm just registering
Other
What is your requirement at this stage?
I require an urgent appointment over the next few days
I require an appointment, but it is not urgent
I am registering in advance, I will be in touch when I need an appointment
I have already made an appointment, I'm just leaving you my details
I am registering to receive information about your services for now, I don't need an appointment
If you need an appointment, please let us know which days and/or times you are available for us to visit (please give options):
How did you hear about us?
Google
Vet referral
Recommendation
Other
Pet's Details and Information
Pet's name
Species
Cat
Dog
Other
Pet's age or date of birth
Breed and approximate weight (if known)
Sex
Male
Female
Any behavioural or handling issues we need to be aware of? Will we need to bring an assistant to help with our examination?
Neutered?
Yes
No
Pet's current illness or symptoms? (leave blank if not applicable)
Any current or recent medications? (leave blank if not applicable)
What veterinary practice is your pet registered at? (if they are not, type N/A)
When was your pet last seen by a vet? (if they have not, type N/A)
May we obtain your pet’s medical history from your current vet?*
Yes
No, I would prefer not
Not registered with another vet
Is your pet insured?
Yes
No
If yes, who is your pet insured with?
Do you have more than one pet to register? Please let us know their Name, Age, Sex, Species and Breed, and any important information about them here.
Do they have the same previous vets as your other pets? We will also contact the vets for their history unless you let us know otherwise.
Please confirm you understand this is not a 24/7 service - and out of hours, or when I am unavailable, you will need to visit a 'bricks and mortar practice' in an emergency. Out of hours provision for The Visiting Vet Company is Provided by Bishopton Vets in Ripon. If you wish to use another practice out of hours it is your responsibility to arrange this.
*
I confirm
Data Protection: We will use the information you give us exclusively for the purpose of registering with The Visiting Vet Company
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Please Opt in to having your details held by us
Please read and agree to our
Terms and Conditions
and
Privacy Policy
*
I agree to the Terms and Conditions and I have read the Privacy Policy
Please verify that you are human
*
Submit
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