Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Cellphone *

Home phone

Work phone

Reminder preference *

Phone
Email
Postcard/Regular mail

Preferred method of contact *

Emergency Contact

In case of an emergency where we would not be able to get a hold of you, who would you like us to contact?

Name *

First

Last

Relationship *

Contact information *

How did you hear about us?

If personal referral, is there someone we can thank for the referral?

If other, please specify

Social media release

Yes I consent to the use of my pet’s name and picture on Alliston Veterinary Services facebook, website, Instagram and Twitter accounts (a separate release form may need to be signed)
No I do not want my pet’s name and/or picture posted on any form of social media

Privacy Statement – we do not share, sell or distribute any client or patient information to any other parties

Pet's name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Colour *

Date of Birth/Age *

Microchip # or Tattoo *

Sex *

Male
Female
Neutered Male
Spayed Female

Previous veterinarian (if any)

Date of last vaccine (if known)

Insurance *

Yes
No

If yes, what insurance comapny? *

Diet *

How much is fed and how often? *

Any medication or supplements? *

Any previous medical conditions including allergies or adverse drug reactions? *

Do you have a second pet? *

Yes
No

Second pet's name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Colour *

Date of Birth/Age *

Microchip # or Tattoo *

Sex *

Male
Female
Neutered Male
Spayed Female

Previous veterinarian (if any)

Date of last vaccine (if known)

Insurance *

Yes
No

If yes, which insurance company? *

Diet *

How much is fed and how often? *

Any medications or supplements? *

Any previous medical conditions including allergies or adverse drug reactions? *

Payment:

Professional Fees are DUE at the time services are rendered. Deposits may be required for pets being admitted to the hospital. We accept Cash, Debit, Visa, and Mastercard. At your request, we will gladly discuss the cost of services and/or prepare a written estimate for recommended procedures.

New Client Form

New Client Form

Emergency Contact

Privacy Statement – we do not share, sell or distribute any client or patient information to any other parties

We Can't Wait to Meet You!

We proudly serve the pets of Alliston and beyond.

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