Welcome to our practice!

Welcome to our practice!

Thank you for giving us the opportunity to care for your pet! Please help us meet your needs better by taking a moment to share some important information. You must be 18 years of age or older to complete this form.
Client Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Contact:
Address

Street Address

Suite/Unit
CityProvincePostal Code
Co-Owner

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Information
Name
Species
Sex
Breed
Colour/Markings
Date of Birth (or approximate age in years)
Allergies/Medical Conditions
Medications
How did you hear about us?
Do you currently use Pet Insurance?
If yes, please enter the Provider and Policy Number below:
Photograph and Video Release: There may be times we would like to share a photo or video of your pet with our social media sites (including but not limited to our website, Facebook, Instagram, etc.) Please indicate your wishes below:
I, the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full and exclusive authority toexecute this consent. I certify that I am 18 years of age or older. I give permission to doctors, staff, authorized agents, orrepresentatives of this hospital to examine, prescribe for, and treat my pets. I agree to pay for all services rendered andmedications, goods, and supplies when purchased. I understand that all fees are due at the time services are rendered and thehospital accepts cash, check, and all major credit cards. I understand that a deposit may be required for surgical or medicaltreatment. I understand that if my pet ever requires overnight hospitalization, there will not be overnight supervision provided. Irelease this hospital from any and all liabilities. By my signature below, I hereby acknowledge that I agree to all of the above andacknowledge the receipt of a copy of this agreement upon request.
Owner/Agent Name
Date

MonthDayYear
Date
Should be Empty:

Welcome to our practice!

Patient Information