Georgina Veterinary Clinic

Georgina Veterinary Clinic

New Client Intake Form
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
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*
YesNo
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.)

Cancelof
Please describe your pet's current diet (Brand name, kibble/canned, raw)*
YesNo
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.
I Agree
YesNo
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*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Georgina Veterinary Clinic

Client Information

Pet Information

Consent