Forty Creek New Client Registration Form

Welcome to Forty Creek Animal Hospital!

THE WAIT IS OVER! Yes, we are open and we are accepting new patients/clients. Please tell us how urgently you need to establish a file with us. We’d like to help!
Please indicate your appointment preference and interest in establishing a new file with us:*

I need an appointment within the next week.I need an appointment within the next month.I would like to establish a file with your hospital for a future appointment.
CLIENT REGISTRATION FORM
Name*

First NameLast Name
Email*
example@example.com
Address*

Address

Street Address Line 2

CityProvince

Postal Code
Province
Phone Number*
Please enter a valid phone number.
Secondary Contact Name

First NameLast Name
Alternate Contact Phone Number*
Please enter a valid phone number.
Alternate Contact Relationship
How did you hear about us?*

Word of MouthGoogleFacebookInstagramNewspaperNextdoorOther online
If you were referred by a friend, who can we thank?
Pet's Name*
Species*
Breed*
Colour*
Sex*

FemaleMale
Spayed/Neutered?*

YesNo
Date of Birth or Approximate Age*
How long have you owned this pet? *
On a normal day, what does your pet eat? Please include any treats or people food*
Do you have your patient's records/last preventative care information?*

YesNo
Please upload any previous vaccine summaries, records, etc.

Cancelof
Would you like us to contact your previous veterinary practice to obtain records?

YesNoN/A
Previous veterinary clinic name and/or website
Any chronic conditions?*
Is your pet on any medications or special diet?*
Any known allergies or drug sensitivities?*
If your patient has a social media account we'd love to follow them! @*
Would you like to submit info for any other awesome pets?

YesNo, that's everyone!
Pet's Name*
Species*
Breed*
Colour*
Sex*

FemaleMale
Spayed/Neutered?*

YesNo
Date of Birth or Approximate Age*
How long have you owned this pet? *
On a normal day, what does your pet eat? Please include any treats or people food*
Do you have your patient's records/last preventative care information?*

YesNo
Please upload any previous vaccine summaries, records, etc.

Cancelof
Any chronic conditions?*
Is your pet on any medications or special diet?*
Any known allergies or drug sensitivities?*
If your patient has a social media account we'd love to follow them! @*
Would you like to submit info for any other awesome pets?

YesNo, that's everyone!
Pet's Name*
Species*
Breed*
Colour*
Sex*

FemaleMale
Spayed/Neutered?*

YesNo
Date of Birth or Approximate Age*
How long have you owned this pet? *
On a normal day, what does your pet eat? Please include any treats or people food*
Do you have your patient's records/last preventative care information?*

YesNo
Please upload any previous vaccine summaries, records, etc.

Cancelof
Any chronic conditions?*
Is your pet on any medications or special diet?*
Any known allergies or drug sensitivities?*
If your patient has a social media account we'd love to follow them! @*
We love taking pictures, and often snap a few during a healthy pet visit or a stay at our hospital. May we have your permission to share these on our social media channels?*

YesNo
I understand that my personal information will be protected and handled in accordance with HIPAA, ensuring it is collected, used, and disclosed only with my knowledge and consent, and maintained with the utmost confidentiality and security. We also share information with pet insurance providers (with whom you have a policy) and referral centers, ERs, and specialists where your pet might be receiving services.*

I understand
All fees are due at the time services are rendered. We accept cash, Master Card, Visa, and Debit. I agree to pay any additional charges related to the cost of collection (including but not limited to collection agency fees, reasonable attorney fees, and court costs), in the event I would fail to pay my bill in full.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
We're here to support you in any way we can. Please take note that if you have any needs or concerns, you can reach out to Lisa, our hospital director, at info@40creekvets.com or +1 289-801-4040.
Should be Empty:

Welcome to Forty Creek Animal Hospital!