New Client Registration

Owner's Name:

Co-Owner Name:

Address:

City:

Postal Code:

Home Phone:

Cell Phone:

Co-owner phone

Email:

Previous Veterinary Hospital

Do you have pet insurance?

Insurance Company

Policy/ Customer #

#1 Pet's Name

Species

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#2 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#3 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

Date

I hereby acknowledge and agree to the terms and conditions set forth. By signing below, I confirm my acceptance and understanding of these terms.

Financial Agreement and Authorization of Treatment: I authorize the above-named pet(s) and agree, irrevocably, that in the consideration of the services to be rendered, I hereby obligate myself to pay the account in accordance with the regular rates and terms of the provider.

As required by law, you are hereby notified that a negative credit report reflecting your credit may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations to our establishment. Should the account be referred to an attorney or collection agency for collection, the undersigned agrees to pay actual attorney's fees and collection expenses.

A DEPOSIT MAY BE REQUIRED, AND FINAL BILLS ARE UPON RELEASE OF THE PATIENT. NO BILLING OR PAYMENT PLANS.

I agree to receive text messages from Renfrew Animal Hospital about my request/appointment. Message & data rates may apply. Message frequency varies. Reply STOP to opt out. Reply HELP for help. View Privacy Policy.

By clicking Submit, you consent to receive SMS messages from Renfrew Animal Hospital related to your request/appointment. Message & data rates may apply. Message frequency varies. Reply STOP to opt out, HELP for help. Privacy Policy.

Signature Of Owner

* Please use this form to request an appointment with us. While we strive to accommodate your preferred day and time, please note that your appointment is not fully booked until you receive a confirmation from us!

Owner's First Name

Owner's Last Name

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Mobile Phone

Confirm Email

First Name

Last Name

Phone

How Did You Find Out About Our Practice ?

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's Name

Species

Breed (if known)

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

New Client Registration

* Please use this form to request an appointment with us. While we strive to accommodate your preferred day and time, please note that your appointment is not fully booked until you receive a confirmation from us!

Please check our hospital hours on Google Maps for the most accurate and up-to-date information. Thank you for trusting us with your pet’s health!

We are closed on Statutory Holidays.

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