New Client Intake Form

Please complete this form as fully as possible 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.

Enter your Pet's Information

Pet's Name

Pet's Date of Birth

Pet's Age

Pet's Breed

Pet's Colour

Pet's Sex

Male

Female

Is your Pet Spayed or Neutered?

Is your Pet Microchipped?

Yes

Do you have Pet's Insurance?

Yes

Enter information about the Pet's Owner

First Name

Last Name

Email *

Primary Phone Number *

Secondary Phone Number

Address

City

Province

Postal code

Country

Is there any other Co-Owner for this pet?

Co-Owner Full Name

Co-Owner Phone Number

By checking this box, I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand and agree to the following:

I authorize the veterinary staff at Fanshawe Veterinary Clinic to examine, diagnose, and treat my pet(s) as deemed necessary.
I consent to the collection, use, and disclosure of my pet's information for the purposes of providing veterinary services and managing my pet's health records.
I agree to adhere to the clinic's policies regarding appointments, cancellations, and payments.
I acknowledge that I am financially responsible for all services rendered during my pet's visit to Fanshawe Veterinary Clinic.

I have read, understood, and agree to the terms and conditions stated above.