New Client/Patient Form – Westboro Animal Hospital

***We are accepting new patients as our schedule will allow.***

Name:*
First Last

Address:*
Street Address Address Line 2 City Province Postal Code

Home Phone:*

Cell Phone:

Work Phone:

Email:*
Enter Email Confirm Email

Place of Employment:

Name of Spouse/Partner:
First Last

Home Phone:

Cell Phone:

Work Phone:

Spouse E-mail:
Enter Email Confirm Email

Spouse Place of Employment:

Patient Information

Patient's Name:*

Breed:*

Gender:*

Birth Date:*

Colour:*

Spayed/Neutered?*

Microchip:

Prior Medical History:

Previous Veterinarian/Animal Hospital's Name:

Does your pet have any chronic illnesses or conditions we should know about? If yes, please describe:

Do you have pet insurance?*

Please provide your pet’s vaccination history (last 3 years):

Reason for today's visit:*

Add 2nd Patient

Patient Information 2

Patient's Name:*

Breed:*

Gender:*

Birth Date:*

Colour:*

Spayed/Neutered?*

Microchip:

Prior Medical History:

Previous Veterinarian/Animal Hospital's Name:

Does your pet have any chronic illnesses or conditions we should know about? If yes, please describe:

Do you have pet insurance?*

Please provide your pet’s vaccination history (last 3 years):

Reason for today's visit:*

Add 3rd Patient

Patient Information 3

Patient's Name:*

Breed:*

Gender:*

Birth Date:*

Colour:*

Spayed/Neutered?*

Microchip:

Prior Medical History:

Previous Veterinarian/Animal Hospital's Name:

Does your pet have any chronic illnesses or conditions we should know about? If yes, please describe:

Do you have pet insurance?*

Please provide your pet’s vaccination history (last 3 years):

Reason for today's visit:*

Hospital Information

Why did you choose to come to our hospital?*

To prevent the spread of infectious diseases and parasites, hospitalized patients must be current with respect to all vaccinations and be free of internal and external parasites. When needed, hospital staff will immunize and provide parasite control of animals in the hospital.

Full payment is required at the time services are rendered or upon discharge if the animal is hospitalized.

A deposit may be required for major medical or surgical cases.

If you have any special concerns regarding cost limits or services to be provided, please let us know at the time of admission.
Otherwise we are authorized to use our best judgement in the treatment of your pet.

Please be advised that cancellation of any non-surgical appointment within 24 hours will result in a cancellation fee of $136.25+tax
For surgical appointments we require 72 hours notice, otherwise there will be a surgical cancellation fee of $425.00 +tax.

**New Clients Only: To secure your first appointment as a new client, we will require a deposit of the full consultation fee. This deposit will cover your appointment consultation. If you need to cancel the appointment, you must give us a minimum of 24 hours' notice to have this deposit refunded. Cancellations with less than 24 hours' notice unfortunately will not be refunded. This will only occur to the very first appointment and not to any other appointment.

Who is responsible for this account?*

Address (if other than owner):*

At this time, we accept VISA, Mastercard and Debit as well as Interac E-Transfer.

We offer a 10% discount for seniors and clients with disabilities. Proof is required to qualify for the discount.

At this time, we accept VISA, Mastercard and Debit as well as Interac E-Transfer.

We offer a 10% discount for seniors and clients receiving ODSP. Proof is required to qualify for the discount.

Consent*
By submitting this form electronically, I, the undersigned, being 18 years of age or older, am the owner or authorized representative of the owner of the animal(s) described above and am authorized to make decisions regarding its care.

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