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Primary Owner Information
As the primary owner, you will be the main contact on file.
Name
*
First
Last
Pronouns
Phone
Email
*
Enter Email
Confirm Email
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
Preferred Method of Contact
*
Phone
E-mail
Secondary Owner Information
Please complete only if applicable
Name
First
Last
Pronouns
Phone
Email
Emergency Contact
In the event of an emergency we will contact this person if neither owner is available
Name
First
Last
Phone
How did you hear about our hospital?
Location
Word of Mouth
Online
If you were referred by a friend, we would love to thank them:
Do you have any children in your home?
Yes
No
Are you a first-time pet owner?
Yes... this is all new to me!
Yes... but I grew up with family pets!
No... but I made need a referesher!
No... I'm very comfortable with pets & veterinary care practices!
Do you have any other pets in your home? Please provide details:
Pet Information
Species
*
Adult Dog (1-7 yrs)
Puppy (0-1 yr)
Senior Dog (7 yrs and older)
Adult Cat (1-7 yrs)
Kitten (0-1 yr)
Senior Cat (7yrs and older)
Pet's Name
*
Date of Birth or Age (if known)
*
Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
Breed of Pet (if known):
Colour:
Microchip Number (if known):
If you are unsure, we can scan your pet while here for their appointment. If you would like to microchip your pet, please let a staff member know.
Your Pets Medical History
Where and when did you obtain your pet?
Previous Veterinary Practice (if applicable):
May we obtain medical history from this clinic?
Yes
No
Is your pet up to date on vaccines?
*
Yes
No
Unknown
Please upload (PDFs/photos) of any documents you received when picking up your pet:
Drop files here or
Breeder contracts, Adoption Paperwork, Vaccine Booklets, Medical Records that will be added to your pets medical record
Please let us know if you have any concerns, questions or if there is any other information you feel we should be aware of:
I would like veterinary support staff to reach out and book me an appointment:
*
Yes - please email me
Yes - please call my phone
Not yet, I will reach out
Photo & Media Consent
*
Yes - please share
No - I'd prefer not
CONSENT TO SHARE PICTURES OF YOUR PET(S) IN A HAPPY AND COMFORTABLE STATE FOR SOCIAL MEDIAL AND/OR EDUCATIONAL PURPOSES:
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New Clients
What to Expect
New Client Registration
Contact
Location & Hours
Emergency
Make an Appointment
RX Refill Request
About Us
Team
Take a Tour
Services
Wellness and Preventative
Puppy & Kitten Exams & Vaccinations
Wellness Plans
Medical Services
Surgical Services
Minimally Invasive Surgery
Nutrition
Specialty Services
Pet Grooming
About Our Grooming Center
Grooming Consent Form – Canine
Resources
Pet Health Checker
Pet Health Library
Pet Heath News
Pet Insurance
Shop Online
Contact Us
Name
*
First
Last
Phone
*
Email
*
Pet Name
*
Preferred Date
*
Date Format: MM slash DD slash YYYY
Preferred Time
*
:
HH
MM
AM
PM
Reason for appointment
*
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