New Client Registration Form

Client Name

Name*

First Last

Email*

Enter Email Confirm Email

Address*

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

Primary Phone*

Secondary Phone

Preferred method of contact.*

Primary
Secondary
Text
Email

Will this be your primary veterinary clinic?

Yes
No

Previous Veterinary Practice

I give permission for Cabbagetown Pet Clinic to post images of my pet to Social Media sites*

Yes
No

How did you hear about us?*

Internet/Search Engine (Google, Bing, Yahoo)
Individual/Direct Referral (friend, family or community)
Social Media (Facebook, Instagram)
Clinic Location (signage/walk-by)

If you were referred by a friend, who can we thank?

Secondary Emergency Contact

Secondary Contact Name*

First Last

Secondary Contact Number*

Email*

Enter Email Confirm Email

Address

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

Does this contact have full authorization to file as co-owner?*

Yes
No

Emergency Authorization: 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
Make financial decisions on my behalf regarding the animal named below up to $ ________ (to be initialed in clinic)

Enter amount:

Patient Information

Pet's Name*

Date of Birth (or best estimate)*

Species*

Breed (if not a purebred, provide best guess ie. Lab Shepherd mix)*

Sex*

Color*

Send us a picture of your pet for our files !

Is your pet microchipped?*

Yes
No

Enter the microchip ID number, if known

Date of last vaccines (if known, best estimate)

What vaccines were given at this time

Privacy*

I agree to the terms and conditions of the Personal Information Policy

Client Name

Secondary Emergency Contact

Patient Information

CONTACT INFORMATION

HOURS OF OPERATION

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