New Client Registration | Fraser Heights Vet, Surrey

Owner's Name:

Co-Owner Name:

Address:

City:

Postal Code:

Home Phone:

Cell Phone:

Co-owner phone

Email:

Previous Veterinary Clinic

Do you consent to us requesting previous medical records?

Do you have pet insurance?

Insurance Company

Policy/ Customer #

How did you hear about us?

#1 Pet's Name

Species

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Color

Date Of Birth

Approximate Age (if date of birth unknown)

#2 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Color

Date Of Birth

Approximate Age (if date of birth unknown)

#3 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Color

Date Of Birth

Approximate Age (if date of birth unknown)

Date

Do we have your consent to post your pet(s) on Social Media? This includes the possibility of them appearing on: Instagram, Facebook, YouTube, TikTok, and our Website.

Authorization

I hereby authorize the veterinarian to examine, recommend treatment for or treat the above-named pet(s). The secondary owner assigned and I assume responsibility for all charges incurred in the treatment and care for this pet. In addition, I understand that these charges must be paid at the time of release/discharge of the pet, and that a deposit may be required for such treatments.

I confirm that the information I have provided above is accurate and truthful.

By clicking SUBMIT you consent to receiving SMS messages from Ridgeview Animal Hospital. Messages and Data rates may apply. Message frequency will vary. Reply Stop to Opt-out of messaging. Reply Help for Customer Care Contact Information. I have read and acknowledged the Privacy Policy.

Signature Of Owner