New Patient Intake Form

Today's Date

Owner's Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Primary Phone

Secondary Phone

Regular Veterinary Clinic Name

Pet Insurance

Yes
No

Pet's Name

Species

Dog
Cat

Breed

Birth Date/Approx Age

Sex

Intact Male
Neutered Male
Intact Female
Spayed Female

Colour

Today's Weight (kg)

Your pet’s weight (in kg) is vital for appropriate dosage of medication. Do not guess! Weigh pet on scale provided on the floor.

What is the reason for your visit today?

Does your pet eat a RAW meat diet?

Yes
No

Date of last vaccine appointment? What vaccines were given at this appointment?

Is your pet vomiting?

Yes
No

How often, and what contents are vomited?

Please note if there is a correlation to food.

Is your pet having diarrhea?

Never/Rarely
Occasionally
Frequently

How many bowel movements per day?

How many bouts of diarrhea per day?

Straining to defecate?

Yes
No

Urination occurance

Normal
Increased
Decreased
Straining

Straining to urinate?

Yes
No
Unsure

Coughing

Occasionally
Frequently
Activity induced
Rarely/Never

Difficulty breathing?

Yes
No

If yes, please describe

Is your pet actively bleeding?

Yes
No

If yes, where?

Sneezing

Rarely/Never
Occasionally
Frequently

Nasal discharge

Has your pet faced any trauma lately?

How has your pet's behavior been lately? Any notable changes?

Current medication, and any chronic illnesses?

Who is authorized to discuss your pets file with our staff? Please list

Your signature authorizes your pet to be examined by the attending Veterinarian at the Hamilton Region Emergency Veterinary Clinic.*

I fully understand that the examination fee is $210.00 + HST payable by Cash, Debit, Visa, and Mastercard

Additional services which may be warranted following the assessment will be discussed with the veterinarian. Following the examination, an estimate will be prepared for any pets that require hospitalization or further treatment. A deposit of 100% will be required before treatment commences. Upon discharge of your pet any balance owing to you will be refunded.

Contact Us

Hours of Operation

Emergencies