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PHONE: 306-782-6620
39 SEVENTH AVE S, YORKTON, SASKATCHEWAN, S3N 3V1
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New Client Registration Form
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Refill Order Request Form
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New Client Registration Form
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
Mailing Address
*
Mailing Address
Street Address
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
Home Phone
*
Cell Phone
*
Best Day-Time Phone
*
Email
*
Enter Email
Confirm Email
Co-owner's Name & Contact #
Name
First
Last
Phone
How did you find out about our practice?
*
Drove By
Personal Referral
Internet Search / Website
Yellow Pages - Phonebook
Yellow Pages - Online
Clinic Sign
Newspaper / Print Media
Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Please indicate your choice of payment method. Payment is due at the time of service.
Method of Payment
*
Please note, we do NOT accept cheques.
Cash
Debit
Mastercard
Visa
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Horse
Cattle
or if other species
Breed (if known)
*
Color
*
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)
MM
DD
YYYY
What vaccines were given at this time
*
Is your pet on any medication or supplements?
*
Yes
No
If Yes, please list the medication or supplements
Which specific diet & how much do you feed your pet per day? What do you feed in addition to the diet? Treats etc.?
*
Does your pet have allergies or drug reactions?
*
Yes
No
Unsure
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
*
Yes
No
Unsure, new pet
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Is your pet covered by insurance?
*
Yes
No
If so, which company?
Do you travel out of province with your pet?
*
Yes
No
If so, where and when?
Please use the following box to give us any other relevant information about your pet
Δ
Home
New Clients
Welcome
What to Expect
Take A Tour
New Client Registration Form
Small Animal New Client Form
Large Animal New Client Form
About Us
About Our Hospital
Contact
Team
Make an Appointment
Prescription/Food Request
Forms
Services
Refill Order Request Form
Anesthesia and Patient Monitoring
After Hours/ Emergency Service
Medical Services
House Calls
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Spring Vaccination Clinic
Large Animal
Pet Health
How-To Videos
Pet Health Checker
Pet Health Library
News
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