Georgina Veterinary Clinic

Georgina Veterinary Clinic

New Client Intake Form
*Please note as of September 5th, 2026 we are currently booking two weeks out for appointments. If you are wishing a second opinion on dental surgery, please be advised we DO NOT offer dental x-rays at this time. If your pet is in need of urgent care, please call the office at 905-722-6571 for further instruction.
Please fill out this form as accurately as possible and a member of our team will contact you within two business days.
Client Information
Primary Contact (must be 18 years of age or older)

First NameLast Name
Secondary Contact (Family or Friend) - if applicable

First NameLast Name
How is the Secondary contact related to the Primary contact?
Primary Phone Number
Please enter a number where you can be reached.Format: (000) 000-0000.
Secondary Contact Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Information
Pet's Name
Please enter the information for the pet with the primary concern
Species
Breed
Colour/ Markings
Date of Birth (if unknown, please estimate approximate age)
How long have you owned this pet?
Gender
Do you have additional pets?
Additional Pets
If your pet has been seen at previous clinics, please write each clinic's name, location and approximate date seen so that we can request records for your pet. If a pet was registered under a different owner name, please indicate the name of the owner beside the clinic where the pet was seen. If no prior Veterinary care, please write N/A
Estimated date of last veterinary visit (Example: June 2023)
Please upload any related documents here (previous records, pictures, etc.)

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Please describe your pet's current diet (Brand name, kibble/canned, raw)
Do you have behavioural concerns with your pet (example: anxious, fearful aggressive)
If yes, has your pet ever been on medication for behaviour? If not, would you be willing to medication prior to appointments/stressful events if recommended

Please check all that apply regarding your pet's demeanour

Rows	Yes	No	Remarks / Notes
Excited / Playful
Calm / Relaxed
Fearful / Timid
Reactive / Assertive
Dominant / Aggressive

Is your pet currently taking any medications or supplements? If so, please list the name and dosage below. If no medications or supplements, please put N/A.
Reason for appointment (example: pet is unwell, update vaccines, health check)

Please read the following items and describe if your pet is experiencing the following symptoms:

Rows	Yes	No	Remarks / Notes
Coughing
Sneezing
Nasal discharge
Eye discharge
Ear discharge
Vomiting
Diarrhea
Abnormal stool
Abnormal urination
Change of Appetite
Lethargy (weakness)
Limping
In pain
Lumps or bumps
Teeth/mouth problems

Please be aware that the administration of Rabies vaccines and the Distemper, Hepatitis, Parainfluenza, and Parvovirusvaccine (DHPP) are a matter of Public Health Law and must be performed by a licensed Doctor of Veterinarian Medicine. These vaccine appointments require a full exam prior to the administration and therefore will have an exam fee attached to the appointment.
Mark that you have read the above statement and understand an exam fee will be charged with the administration of the Rabies & DHPP vaccines
Has your pet ever had an adverse reaction to a medication or vaccine?
If yes, please provide a detailed description of the adverse reaction and symptoms that were experienced.
Additional concerns we should be aware of:
Consent
Preferred method of contact
Pet Owner's Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Georgina Veterinary Clinic

Client Information

Pet Information

Consent