New Client Form – Walkers Line Veterinary Clinic

Primary Owner Information

Name*

First Last

Prefix

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone*

Cell Phone

Work Phone

Email

Are you 60 years of age or older?

Yes
No

Secondary Owner Information

Name

First Last

Prefix

Address

Street Address Address Line 2 City Province Postal Code

Home Phone

Cell Phone

Work Phone

Email

Emergency Contact Information

Name

First Last

Prefix

Address

Street Address Address Line 2 City Province Postal Code

Home Phone

Cell Phone

Work Phone

Email

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*

First Last

Pet Information

Name*

Age/DOB

Species*

Breed*

Colour*

Sex*

Male
Female

Spayed or Neutered?*

Yes
No

Microchip*

Pet Information

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?*

Yes
No

Will you be continuing care with us?*

Yes
No

Do you have other pets?:*

Yes
No

(IF YES)# of dogs?

(IF YES)# of cats?

(IF YES) other?

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.*

Yes
No

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

Signature*

First Last

Date of Signature*

Primary Owner Information

Secondary Owner Information

Emergency Contact Information

Pet Information

Pet Information

Contact Us

Hours of Operation