New Client/Pet Registration Form

Please fill out this form if you are a new client and you have already set up an appointment with us or if you are an existing client and are scheduled to bring a new pet to Nanaimo Veterinary Hospital for the first time.

NEW CLIENT INFORMATION

Date of scheduled appointment

Full Name(s)

E-mail

Street address

City and Province

Postal code

Primary phone number

Phone 2

Other individuals authorized to make medical decisions

Phone

How did you learn about our hospital

NEW PATIENT INFORMATION

Name of pet

Species

Breed

Colour

Birthdate or approximate age

Microchip number if applicable

Pet insurance provider if applicable

Vaccine history (date and type of last vaccines)

Name of all previous veterinary hospitals this pet has attended

Do you give us permission to obtain records from your previous veterinary hospitals listed above

Digital Signature (please type name in lieu of signature)

#header_text h2#site_subheading a, #header_text h2#site_subheading{ color:#000000 } @media (min-width: 650px) { #header_text h2#site_subheading a, #header_text h2#site_subheading{ } }