New Client Form

First Name

Last Name

Prefix

Address

Street Address

Address Line 2

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

Are you 60 years of age or older?

Yes No

First Name

Last Name

Prefix

Address

Street Address

Address Line 2

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

First Name

Last Name

Prefix

Address

Street Address

Address Line 2

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

In the event that I am unavailable, the individual named above is authorized to: Make medical decisions on my behalf and the animal named below and make financial decisions on my behalf regarding the animal named below up to $*

I agree to the above.

Signature

Pet Name

Age/DOB

Species

Breed

Colour

Sex

Spayed or Neutered?

Microchip

Brief Medical History

Does your pet have any medical conditions? Please list:

Is your pet on any medications or supplements? Please list (please include flea/tick/heartworm/preventative(s):

Does your pet have any allergies (food/environmental/medications)? Please list:

Previous Veterinary Hospital:

Would you authorize us obtaining your pet’s medical records?

Will you be continuing care with us?

Do you have other pets?:

Photo Consent: We love sharing your adorable pets on social media! Do we have your permission to share your pet’s image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared.

Do you authorize Walkers Line Veterinary Hospital to share my pet’s photo and story?

Signature

Date of Signature

First Name

Last Name

Prefix

Address

Street Address

Address Line 2

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

Are you 60 years of age or older?

Yes No

First Name

Last Name

Prefix

Address

Street Address

Address Line 2

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

First Name

Last Name

Prefix

Address

Street Address

Address Line 2

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

I agree to the above.

Signature

Pet Name

Age/DOB

Species

Breed

Colour

Sex

Spayed or Neutered?

Microchip

Brief Medical History

Does your pet have any medical conditions? Please list:

Is your pet on any medications or supplements? Please list (please include flea/tick/heartworm/preventative(s):

Does your pet have any allergies (food/environmental/medications)? Please list:

Previous Veterinary Hospital:

Would you authorize us obtaining your pet’s medical records?

Will you be continuing care with us?

Do you have other pets?:

Do you authorize Walkers Line Veterinary Hospital to share my pet’s photo and story?

Signature

Date of Signature

We are always closed on • Statutory Holidays.

(905) 336-6222

New Client Form

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Hours of Operation

We are always closed on • Statutory Holidays.

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