Client Intake Form

Road Construction Alert: Please be aware that there is ongoing construction on Bedford Park. Parts of the street are closed, but there is still access to our parking lot. If you have any trouble finding us, please call us for assistance. Thank you for your understanding

OWNER INFORMATION

Owner's Full Name *

Owner's Phone Number *

Co-Owner's Name

Co-Owner's Phone Number

Address *

City *

Province *

Postal Code *

Email Address *

Name of your regular veterinary clinic *

I consent to Vaughan-Richmond Hill Veterinary Emergency Clinic contacting my pet's regular vet for medical history *

Yes
No

Do you have pet insurance? *

Yes
No

PET INFORMATION

Pet's Name *

Species *

Breed *

Colour *

Date of Birth *

Gender *

Is your pet up to date on vaccinations? *

Yes
No

Is your pet up-to-date on their rabies vaccine? *

Yes
No

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Client Intake Form

OWNER INFORMATION

PET INFORMATION

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