CLIENT AND PATIENT INFORMATION
Thank you for giving the White Rock Veterinary Hospital the opportunity to care for your pet. So that
we may become better acquainted, please complete the following:
ABOUT YOURSELF:
Circle one: (Mr) (Mrs) (Mr & Mrs) (Ms) (Miss) (Dr)
Your Last Name:
______________________________ First Name: ___________________________
Spouse Last Name: ______________________________ First Name: ___________________________
Address: ___________________________________________________ City: _____________________
E-mail Address: ______________________________________________ Postal Code: _______________
Phone Number (Home): ___________________________ Your Work Phone: _____________________
Spouse Phone Number: ___________________________ Other Phone Number: __________________
Whom may we thank for referring you?
Yellow Pages [ ] Welcome Wagon [ ] Sign [ ] Friend (name)____________ Other: __________________
Does your pet have insurance? [yes] [no]
Insurance Company Name: ____________________________
I hereby acknowledge that White Rock Veterinary Hospital does not bill, and payment is expected at the
time services are rendered. We accept Cash, Visa, MasterCard, Debit and American Express. Sorry, we
do not accept Cheques.
Signature: ______________________________________________________________________
ABOUT YOUR PET:
Species (Circle One): Canine
Feline
Avian
Rodent
Lagomorph
Name: _______________________________________________ Breed: ___________________________
Date of Birth: __________________________________________ Colour/Markings: __________________
Tattoo/Microchip: _______________________________________
Sex: Male [
] neutered [yes] [no]
Female [ ] spayed [yes] [no]
DATE OF LAST VACCINATIONS:
CANINE: Distemper/Parvo __________________
FELINE: Distemper/Rhino ___________ _
Corona
__________________
Leukemia
_____________
Kennel Cough
__________________
Rabies
_____________
Rabies
__________________
Lyme Disease
__________________
Where did you purchase/adopt your pet? _______________________________________________________
Is your pet currently on a special diet or medication? _______________________________________________
When was your pet last dewormed or checked for worms? __________________________________________
RESTRAINT OF PETS
DOGS: For their own safety, dogs should be on a leash in the waiting room. If you have forgotten your
leash at home, please ask us for a complimentary one.
CATS: Please bring cats in a carrier, or on a secure harness and leash. They are easily frightened and may
escape into our parking lot if not properly confined.