Owner Information

Owner First Name

Owner Last Name

Preferred Name

Primary Phone

Mobile Phone

How would you prefer to be contacted?

Phone

Communication Preferences

Appointment reminders – phone

Appointment reminders – email

Appointment reminders – text

General clinic/educational communications

No general clinic/educational communications

No automated reminders

Co-Owner / Legal Owner

An emergency contact or authorized representative is not automatically a legal owner. If ownership changes, please notify Napanee Veterinary Hospital in writing so we can update the medical record.

Full Name

Relationship

Phone

Email Address

Legal Owner?

Yes

Authorized Representatives & Decision Makers

Please identify exactly what this person may do on your behalf. Someone listed only as an emergency contact does not automatically have decision-making authority.

Full Name

Relationship

Phone

What can this person do on you behalf?

Receive Information

Routine Medical Decisions

Emergency Medical Decisions

Financial Decisions

Euthanasia

No one other than the legal owner(s) is authorized unless separately documented in writing

Emergency Contact

Emergency Contact Name

Relationship

Phone

Alternate Emergency Contact Name

Relationship

Phone

Patient Information

Your Pet's Name

Species

Breed

Date of Birth or Approximate Age

Sex

Male

Female

Spayed/Neutered?

Spayed

Neutered

Unaltered

Colour/Markings

Microchip Number

Microchip Registry

Rabies Tag Number

Tattoo / Other ID

Primary Owner

Do you have pet insurance?

No pet insurance

Insurance information provided

Insurance information to follow

Pet Insurance Provider

Policy / Member #

Current Weight (if Known)

Previous Veterinary Care

Has your pet seen a previous veterinarian?

Yes

Previous Veterinary Hospital

Previous Veterinarian

Phone

Clinic Email / Fax

Approximate Last Visit

City / Town

Medical & Preventive History

Does your pet have any allergies or intolerances that you know of? Please list them.

Has your pet had any previous illnesses, hospitalizations, or surgeries? Please list them.

Has your pet ever had a reaction to anesthesia?

Does your pet have any previous illnesses, hospitalizations, or surgery? Please list them.

Is your pet currently taking any medications, vitamins, or supplements? Please list them.

What is your pet currently eating? List all foods, treats, and chews.

Does your pet have any fear, anxiety, or handling concerns?

Does your pet have any history of aggression or biting?

Does your pet have any special dietary needs?

Do you have any concerns about your pet or any other important medical information to share?

Current Preventive Care

Vaccinations

Flea/Tick

Heartworm

Intestinal Parasite Prevention

Please list any other preventive care.

Euthanasia & End-of-Life Authorization Preference

This records your standing preference if you cannot be reached. It does not replace the informed consent discussion and authorization required at the time of euthanasia.

Only a legal owner may consent to euthanasia.

I authorize the person identified below to consent to euthanasia on my behalf if I cannot be reached.

Authorized Person – Full Name

Relationship

Phone

I understand that a veterinarian must use professional judgment regarding whether euthanasia is appropriate and that euthanasia consent is separate from authorization for routine or emergency treatment.

Authorization to Request Veterinary Records

I authorize Napanee Veterinary Hospital to request relevant medical records from the previous veterinary hospital(s) identified on this form for the purpose of coordinating my pet’s care.

Yes, request records

No, I will provide records myself

Client Acknowledgement

Please check all boxes.

The information I have provided is true and complete to the best of my knowledge.

I have identified all known legal owners of the patient(s) listed on this account.

The people identified as authorized representatives have the authority I have granted, subject to the limits I have indicated.

I understand that an emergency contact is not automatically authorized to make medical, financial or euthanasia decisions.

I understand that veterinary consent is an ongoing process and that specific consent may be required for examinations, diagnostics, treatment, anesthesia, surgery, hospitalization or euthanasia.

I understand that I am responsible for fees for services authorized by an authorized representative acting within the authority I have provided or by me.

I agree to notify Napanee Veterinary Hospital in writing of changes to ownership, authorized representatives, contact information or decision-making authority.

Date

By submitting this form, I authorize Napanee Veterinary Hospital to provide medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantees can be made regarding the outcomes of treatments and acknowledge that it is my responsibility to understand any associated risks. I agree to pay for all services to which I consent, and I understand that full payment is required before any diagnostics or treatments can begin.

New Client and Patient Welcome Form

Option 1

Complete Online

Option 2

Complete & Print

Option 3

Complete on Arrival