Veterinary Care in Simcoe, ON | Colborne Veterinary Clinic

New Client Registration Form

Thank you for considering our clinic as your pets’ provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to seeing you in the future.

Please complete this form prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Owners Name

First Name*

Last Name*

Address - Street Address*

Address Line 2

City*

State / Province / Region

ZIP / Postal Code*

Country*

Day-Time Phone*

Evening Phone

Mobile Phone*

E-mail*

Confirm Email*

Co-owner's Name & Contact #

First Name

Last Name

Phone

How did you find out about our practice?
Clinic Location
Personal Referral
Internet Search / Website
Yellow Pages
Clinic Sign
Newspaper / Print Media
Other

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

Or if other species

Breed (if known)*

Color*

Date of Birth or Age (if known)*

Special Identification (tattoo, microchip, etc.)*

Sex*

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)*

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?*
Yes No

If Yes, please list the medication or supplement*

What food does your pet eat?*

Does your pet have allergies or drug reactions?*
Yes No

If Yes, please list the allergies and reactions*

Are there any current or past medical conditions of which we should be aware?*
Yes No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions*

Please use the following box to give us any other relevant information about your pet