South Shore Veterinary Clinic

South Shore Veterinary Clinic
New Client Form

Thank you for giving us the opportunity to care for your pet. So that we may become better acquainted, please complete the following form.

Owner 1:		Owner 2:
Address
City
Postal Code
Phone:	Work Phone:	Cell:	Fax:

Email Address
How did you become aware of our clinic?
If you were referred to us, whom may we thank?
Other Authorized Contact

Name:	Breed:	Species:	Birth Date:
Colour:		Sex: Male - Female -	Spayed/Neutered: Yes - No -
Date of last vaccines given: Date of last heartworm test:
Any previous serious illnesses or surgeries?
Any allergies to vaccinations or medications?
Is your pet on any special diets or medications?

Name:	Breed:	Species:	Birth Date:
Colour:		Sex: Male - Female -	Spayed/Neutered: Yes - No -
Date of last vaccines given: Date of last heartworm test:
Any previous serious illnesses or surgeries?
Any allergies to vaccinations or medications?
Is your pet on any special diets or medications?

Name:	Breed:	Species:	Birth Date:
Colour:		Sex: Male - Female -	Spayed/Neutered: Yes - No -
Date of last vaccines given: Date of last heartworm test:
Any previous serious illnesses or surgeries?
Any allergies to vaccinations or medications?
Is your pet on any special diets or medications?
As legislated by the Privacy Act of Ontario, South Shore Veterinary Clinic would like to inform you of the purpose for collection of the above information. The purpose for collecting the above information is to effectively communicate with our clients, maintain complete and accurate client/patient files and for billing purposes. This information will be kept confidential.