Client Questionnaire

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 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?

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 or Facebook page 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”.

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	Closed until further notice
Sunday	Closed

PATIENT/CLIENT INFORMATION

Contact Us

Hours of Operation

Emergency Info