Client Details

Title

Other

Surname *

First Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone *

Work Phone

Mobile Phone

Email *

How did you hear about us?

Other

Patient Details

Pet's Name *

Birth Date (or approx. age) *

Sex *

Male
Female
Unknown

De-sexed *

Yes
No
Unknown

Species (dog, cat, rabbit etc.) *

Breed

Color

Does your pet have a microchip? *

Yes
No

If your pet is insured, please provide details including the insurer, policy number and policy start date

Previous vet hospital (if applicable)

Do you have second pet?

Yes
No

Pet's Name *

Birth Date (or approx. age) *

Sex *

Male
Female
Unknown

De-sexed *

Yes
No
Unknown

Species (dog, cat, rabbit etc.) *

Breed

Color

Does your pet have a microchip? *

Yes
No

If your pet is insured, please provide details including the insurer, policy number and policy start date

Previous vet hospital (if applicable)

Do you have third pet?

Yes
No

Pet's Name *

Birth Date (or approx. age) *

Sex *

Male
Female
Unknown

De-sexed *

Yes
No
Unknown

Species (dog, cat, rabbit etc.) *

Breed

Color

Does your pet have a microchip? *

Yes
No

If your pet is insured, please provide details including the insurer, policy number and policy start date

Previous vet hospital (if applicable)

Dundas Veterinary Hospital may take a photo of your animal for identification purpose. We may use these photos on our website or social media platform such as Facebook or Instagram. Please advise us if you do not wish for us to take such photos of your animal.

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