Please enable JavaScript in your browser to complete this form.Primary Owner *FirstLastPrimary Phone numberPrimary Phone numberPrimary Owner Email *Secondary OwnerFirstLastRelationship to OwnerSpouseFriendFamily MemberCo-workerSecondary Owner Email Secondary Owner Phone Owner Address:CityProvincePostal Code Medical History - Is there a previous animal hospital we can contact for your pet’s previous medical history?Hospital NameHospital EmailHospital PhonePets Name *FirstLastBreed *ColorPet Date of birth:SexMicrochip NumberSpayed/Neutered?Does your pet have health insurance?Name of insurance companyPolicy NumberCan we take your pets photo?This would be added to their account and potentially social media.Your Pet's social media accountCurrent Medications/SupplementsPlease list all medications, supplements, and preventatives your pet is currently taking. Or N/A if they are not on any.Would you like to discuss any medications, supplements and/or preventatives with the veterinarian?YesNoHave you noticed any of the following?CoughingVomitingLamenessSneezingDiarrheaPainBehavioural ChangesNew LumpsDifficulty standing/jumping/playingPresence of fleas, ticks, or tapewormsChanges in appetiteDecreased grooming/change in grooming patternsPlease select all that are present in your pet.Has your pet traveled recently or does he/she travel with you routinelyYesNoDietPlease list the specific name(s) of the food that you are feeding (include both dry and wet food). How much do you feed your pet, and how many times a day?Are these specifically measured amounts?Does your pet receive treats/human food?Would you like to discuss your pet’s nutrition with the veterinarian?Other QuestionsWould you like more information on any of the following? (please check all that apply)Pet health insuranceLyme diseaseFlea and tick preventionHeartworm diseaseInternal parasitesVaccinesTraining BehaviorRate your pet’s water consumptionHas this changed recently?YesNoHow did you hear about us?WalkedDrive bySignageInternet searchSocial mediaWord of mouthFriend or FamilyName of referral:Submit To schedule an appointment, please call into the clinic to discuss availability.