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Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). If you have multiple pets, kindly fill out the form for each pet.


Primary Owner Information

First Name:

Last Name:

Street Address:

Address Line 2:

City:

State / Province / Region:

ZIP / Postal Code:

Country:

Day-Time Phone:

Evening Phone:

Mobile Phone:

Email:

 

Emergency Contact Information

First Name:

Last Name:

Phone:

 

Communication Consent

By clicking the Yes box below, you are consenting to receive text message communications from us.

YES   NO 


How did you find out about our practice?

If Other, please specify:

If 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 Information

Pet's Name:

Species:

Breed (if known):

Color:

Date of Birth or Age (if known):

Special Identification (tattoo, microchip, etc.):

Sex:

Previous Veterinary Practice (if any):

Previous Veterinarian (if any):

Date of last vaccines (if known):

What vaccines were given at this time?

Is your pet on any medication or supplements?

If Yes, please list the medication or supplements:

What food does your pet eat?

Does your pet have allergies or drug reactions?

If Yes, please list the allergies and reactions:

Are there any current or past medical conditions of which we should be aware?

If 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:

 

Social Media Consent

 Photos are added to your pet’s medical record and may be used in social media. If we were to take a picture of your pet, we would like your permission to use it in our social media content, promotional materials and/or publicity efforts. These photo may be used in publications, print ads, direct-mail pieces, electronic media (e.g. video, website) or other forms of promotion in perpetuity without remuneration or further consent. Your pet’s name may be shared, but your identifying information would not be.

I authorize the usage of my pet's photographs on social media.

Yes   No

 

If yes, want to be tagged in our posts? Provide us with your pet's Instagram account/username!

I would like a radio button section just before Additional Comments where it says, "Is this a rush refill request? ($25 fee will apply.)" Options are yes or no.

 Yes   No