New Client Registration Form Step 1 of 2 50% Owner's NameOwner Name* First Last Co-owner's Name & Contact #Co-Owner Name First Last Co-Owner Cell NumberPreferred method of contact:*PhoneEmailAddressAddress* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email Address*Home Number*Work Number*Cell Number*How did you find out about our practice?*Clinic LocationPersonal ReferralInternet Search / WebsiteYellow PagesClinic SignNewspaper / Print MediaIf Personal Referral, is there someone we can thank for this referral?Please use this area to give us any other relevant information about yourself or your family* Pet InformationSpecies*DogCatRabbitPet's Name*Breed (if known)*Color*Age (if known)*Special Identification (tattoo, microchip, etc.)*Sex*Neutered MaleSpayed FemaleMaleFemaleUnknownObtaining your pet’s medical records from your previous veterinarian is essential for the continuity of patient care. Therefore, we will not see a patient unless we are given permission to contact the previous veterinarian for medical records. If you agree to the aforementioned statement, please provide us the name of your previous veterinary clinic and, if available, previous veterinarian. Thank you!Previous Veterinary Practice (if any)*Previous Veterinarian (if any)*Do you bring your pet in for health exams and/or vaccinations on a yearly basis?*YesNoDo you have heart-worm/Lyme blood testing done yearly? (For Dogs Only)*YesNoDate of last vaccines (if known)* What vaccines were given at this time*Is your pet on any medication or supplement?*YesNoIf Yes, please list the medication or supplement*Do you have your pet on heart-worm, tick, and/or flea medication?*YesNoIf so, which months of the year?*Which product(s) do you use?*What does your pet eat? (Brand, amount, frequency)*Does your pet have allergies or drug reactions?*YesNoIf Yes, please list the allergies and reactions*Are there any current or past medical conditions of which we should be aware?*YesNoIf Yes, please comment on the condition(s) and indicate if they are current or past conditions*Please use the following box to give us any other relevant information about your pet*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
