New Client Registration - Coffs Harbour Veterinary Hospital

We're excited to welcome you to Coffs Harbour Veterinary Hospital and we hope this is the start of a long and mutually beneficial relationship. To help us get to know you and your pet, we ask that you complete this new client form so that we can best meet your requirements during your visit. If you are joint pet owners, please decide who will be the main owner and enter their details as the client. Please enter other owners as authorised parties (see further down the form). Owners under 18 years of age must have an adult (eg parent or guardian) complete this form as the client.

CLIENT DETAILS - One person only please

Title (eg Mr Mrs Ms Dr)

Mr.

First name

Test

Last name

Test

Preferred first name

Preferred phone number

0438521577

Other phone numbers

vicky@coffsharbourvet.com.au

Postal address

test

Residential address (if different)

authorised parties

Please enter here any family members (or others) who are authorised to participate in your pet's care. Please indicate whether they are authorised to: - make decisions regarding your pet's treatment (T) - be given information regarding your pet's medical history and treatment (H) - access your invoice & payment information (P) - receive communications regarding your pet (C)

The below-listed person is authorised to:

Authorised person's full name, relationship to you and contact phone number (may list more than one person if same authority applies)

The below-listed person is authorised to:

Authorised person's full name, relationship to you and contact phone number (may list more than one if same authority applies)

Please enter here any other authorised persons and what authority they have (T/H/P/C)

ANIMAL DETAILS - PET 1

Pet's name

Testy

Species

Breed

?

Colour

Black

Sex (eg Male, Female, Unknown)

female

Desexed? (Yes, No, Unsure)

yes

Age (and/or date of birth if known)

2000-03-28

PET 1 MEDICAL HISTORY

Date of last vaccination (if known)

Previous/current significant illnesses or injuries

Please list all medications and supplements that your pet is currently taking.

Any known adverse reactions to medications or other treatments

Previous veterinary hospital/s attended

ANIMAL DETAILS - PET 2

Pet's name

Species

Breed

Colour

Sex (eg Male, Female, Unknown)

Desexed? (Yes, No, Unsure)

Age (and/or date of birth if known)

pet 2 medical history

Date of last vaccination (if known)

Previous/current significant illnesses or injuries

Please list all medications and supplements that your pet is currently taking.

Any known adverse reactions to medications or other treatments

Previous veterinary hospital/s attended

If you have more than 2 pets, please list the other's details here (Name, breed, colour, sex, age, plus any significant information about their medical history, medications or adverse reactions)

consent to obtain pet's history

I consent to Coffs Harbour Veterinary Hospital obtaining information about my pets' previous medical histories from any and all previous veterinary hospitals attended. I agree to pay for this if a fee is required. Please note: answering NO to this question may adversely affect our ability to effectively treat your pet.

Please enter clinic name and contact details for all previous veterinary clinics attended.

PET HEALTH INSURANCE

Please list each pet's insurance company and policy number

What is the start date of your policy?

CONSENT TO PHOTOGRAPHY

I consent to Coffs Harbour Veterinary Hospital taking photographs or using my pet's images for educational or promotional purposes e.g. website or social media.

consent to share history with new owner

If I, in future, sell or give my pet to a new owner, I consent for Coffs Harbour Veterinary Hospital to pass on information about that pet's medical history to the new owner.

HOW DID YOU HEAR ABOUT US?

Please select how you found out about Coffs Harbour Veterinary Hospital

Other

If you were referred by someone, whom may we thank?

OTHER COMMENTS

Please make any other comments here.

We would love you to share a photo of you and your pet for your file &/or our display. Please email it to info@coffsharbourvet.com.au

declaration

By submitting this form, I acknowledge that I am the owner or agent representing the owner of the pet named above and that the information here is true and correct. I understand that I may change my authorisations and consents at any time by notifying the veterinary hospital in writing.

Please sign here