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AFTER HOURS EMERGENCY: (905) 641-3185
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Alternative and Complimentary Therapy
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Wellness Payment Program
Additional Services
Online Telehealth
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Pet Insurance Info
Pet Health Library
How-To Videos
Pet Health Checker
News
Links
Product Safety Recalls and Alerts
Animal Food Recalls and Alerts
Tel: (905) 295-8111
Press enter to begin your search
New Client Registration Form (Not Currently Accepting New Clients)
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.
Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner's Name
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone (work)
Phone (home)
Phone Cell
Fax
Email
*
Enter Email
Confirm Email
Co-owner's Name & Contact #
Name
First
Last
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone (work)
Phone (home)
Phone (cell)
Fax
Email
Enter Email
Confirm Email
Emergency Contact
Name
First
Last
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone (work)
Phone (home)
Phone (cell)
Fax
Email
Enter Email
Confirm Email
Authorization privileges
In the event that I am unavailable, the individual named above as Emergency Contact is authorized to make medical decisions on my behalf regarding the animals I have registered under my name and...
I am financially responsible for all costs
They have a limit for which I am responsible
Maximum allowable authorization privilege for emergency contact:
How did you find out about our practice?
Clinic Location
Personal Referral
Internet Search / Website
Yellow Pages
Clinic Sign
Newspaper / Print Media
Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Breed (if known)
Color/markings
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Information changes
*
As the owner of the above mentioned pet I understand that it is my responsibility to notify Chippawa Animal Hospital in writing of any changes in the information above
I understand
New Client Registration Form (Not Currently Accepting New Clients)
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.
Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner's Name
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone (work)
Phone (home)
Phone Cell
Fax
Email
*
Enter Email
Confirm Email
Co-owner's Name & Contact #
Name
First
Last
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone (work)
Phone (home)
Phone (cell)
Fax
Email
Enter Email
Confirm Email
Emergency Contact
Name
First
Last
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone (work)
Phone (home)
Phone (cell)
Fax
Email
Enter Email
Confirm Email
Authorization privileges
In the event that I am unavailable, the individual named above as Emergency Contact is authorized to make medical decisions on my behalf regarding the animals I have registered under my name and...
I am financially responsible for all costs
They have a limit for which I am responsible
Maximum allowable authorization privilege for emergency contact:
How did you find out about our practice?
Clinic Location
Personal Referral
Internet Search / Website
Yellow Pages
Clinic Sign
Newspaper / Print Media
Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Breed (if known)
Color/markings
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Information changes
*
As the owner of the above mentioned pet I understand that it is my responsibility to notify Chippawa Animal Hospital in writing of any changes in the information above
I understand
New Clients
What to Expect
Gallery
Make an Appointment
About Us
Location & Hours
Team
Rx and Food Form
Services
Alternative and Complimentary Therapy
Emergency and/or Extended Care
Medical Services
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Wellness Payment Program
Additional Services
Online Telehealth
Pet Health
Pet Insurance Info
Pet Health Library
How-To Videos
Pet Health Checker
News
Links
Product Safety Recalls and Alerts
Animal Food Recalls and Alerts
Tel: (905) 295-8111