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New Patient/Client Questionnaire – **Please fill out only if you are requesting an appointment!
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New Patient/Client Questionnaire - **Please only fill out if you are requesting an appointment!
PATIENT/CLIENT INFORMATION
Please fill out this form, even if you are an existing client. It allows us to track permissions specific to each pet, and it gives us an opportunity to confirm contact information for you. Thank you for trusting us with your pet's health!
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
*
Work Phone
Cell Phone
Alternate Phone
Email
WHICH NUMBER IS BEST TO REACH SOMEONE DURING THE DAY?
*
Is it acceptable to call your work to confirm an appointment, or if your pet is in hospital?
Yes
No
Is it acceptable to e-mail or text message you with information about your pet(s)?
*
Yes
No
Pet's Name
*
Breed
*
Colour
Sex
*
F
M
Date of Birth
Last Vaccinated
*
Neutered?
Yes
No
Previous drug or vaccination reactions?
Yes
No
If yes please specify
Previous medical/surgical problems?
Any seizures?
Yes
No
Previous veterinary clinic
*
Phone
Professional fees are due at time of services. We do not accept cheques. What is your preferred form of payment?
*
CASH
VISA
MASTERCARD
INTERAC
Does your pet have a microchip identification implant?
*
Yes
No
Does your pet have health insurance?
*
Yes
No
If yes with which company?
If you are interested in either of the above services please ask one of our team members.
HOW DID YOU HEAR ABOUT US?
Friend
Another vet clinic
Our Website
Google Search
Yellow Pages
Other
Please Specify so we know who to thank!
PLEASE NOTE TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, HOSPITALIZED AND BOARDED ANIMALS MUST BE CURRENT ON ALL VACCINES AND FREE OF INTERNAL & EXTERNAL PARASITES.
You agree to give consent for us to post pictures of your pet on our Website, Facebook, or other Social Media pages and this agreement will remain in full force until you provide us with a written revocation of the consent.
*
Yes
No
Electronic Signature
*
I agree
Should your pet require it, vaccines or parasite control will be provided as needed. The undersigned hereby gives consent to the collection and use of personal information about themselves in accordance with “The Personal Information Protection and Electronic Documents Act”.
Covid 19 Information
About Us
Our Hospital
Meet Our Team!
Location & Hours
New Clients
What to Expect
New Patient/Client Questionnaire – **Please fill out only if you are requesting an appointment!
Services
Anaesthesia and Patient Monitoring
Emergency and/or Extended Care
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Additional Services
Pet Health
Pet Health Library
Pet Health Checker
How-To Videos
News
Online Store