New Client Registration Form

CLIENT INFORMATION

CLIENT #1: Full Name

Preferred Pronoun

Owner? *

Yes
No

Email Address *

Address *

City *

Province *

Postal Code *

Cell phone *

Home Phone

Preferred method of contact *

Cell phone
Email
Text
Home phone

EMERGENCY CONTACT INFORMATION

CANNOT be Client 1 or 2 on file!

Emergency Contact Name *

Email *

Cell Phone *

Home phone

In the event that I am unavailable, the individual named above is authorized to make medical decisions on my behalf regarding the animal named below. *

Yes, the individual is authorized
No, the individual is NOT authorized

PATIENT INFORMATION

Pet's Name

Species *

Sex *

Breed *

Colour *

Markings *

Microchip *

Date of Birth *

Known Drug Allergies *

Current Medications or Supplements *

Current Diet *

Medical Conditions *

I have an additional pet *

Previous Veterinarian/Clinic Name *

Previous Veterinarian/Clinic Phone

Signature *

Client Name & Date

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *