New Client Registration - Wilmot Veterinary Clinic

Client Care Center

Save time and fill our your new client registration form online! We look forward to seeing you and your pet soon.

Pet Owner's Name *

First

Last

Spouse/Significant Other/Co-Owner Of Your Pet

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone *

Work Phone

Mobile Phone

Spouse/Significant Other Phone

E-mail *

The emergency contact you choose must have the ability to make decisions regarding your pet's care if you are unreachable by phone.

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How did you hear about us?

Patient Information

Pet's Name *

Pet Type *

Colour *

Markings

Breed *

Pet's Date of Birth *

Pet Sex *

Is your pet fixed? *

Tattoo

Microchip #

Previous Veterinary Clinic:

Do you have pet insurance?

Consent to request medical records from previous veterinary clinic?

Consent to release pet’s vaccine history to a groomer, kennel, or animal shelter if requested?

Consent to release your phone number if your pet is found at large?

Last Veterinary Treatment:

Prior Vaccine Reactions?

Any known drug allergies or reactions?

Prior illness or surgery?

Please list all current medications.

Diet restrictions or supplements?

Reason for visit?

Please click here to read our updated terms and conditions on our clinic policies page.

I agree to the terms and conditions as outlined under the clinic policies. *

I Agree