New Client Registration - Coffs Harbour Veterinary Hospital - Created Date 03 Sep, 2025
Coffs Harbour Veterinary Hospital
4 Lyster Street
Coffs Harbour New South Wales 2450 AU
02 66521577
info@coffsharbourvet.com.au
EMAIL
CALL
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)
*
First name
*
Last name
*
Preferred first name
Preferred phone number
*
Other phone numbers
Email
*
Postal address
*
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:
Receive information regarding my pet's medical HISTORY
Access my INVOICE / PAYMENT information
Receive COMMUNICATIONS regarding my pet
Make decisions regarding my pet's TREATMENT
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:
Make decisions regarding my pet's TREATMENT
Receive information regarding my pet's medical HISTORY
Access my INVOICE / PAYMENT information
Receive COMMUNICATIONS regarding my pet
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
*
Species
*
Select
Dog
Cat
Bird
Guinea Pig
Reptile
Rabbit
Horse
Other
Breed
*
Colour
*
Sex (eg Male, Female, Unknown)
*
Select
Female
Male
Desexed? (Yes, No, Unsure)
*
Select
Yes
No
Age (and/or date of birth if known)
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.
Yes
No
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.
Yes
No
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.
Yes
No
HOW DID YOU HEAR ABOUT US?
Please select how you found out about Coffs Harbour Veterinary Hospital
I saw the practice
Search engine e.g. Google
Social media e.g. Facebook
Word of mouth
Practice programs e.g. Puppy school
Advertising e.g. radio
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
*
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AMENDMENT
Amendment Description *
Update estimate *
I, the undersigned, acknowledge that I have read and understood this amendment, which has been fully explained to me, and that it modifies the original consent form to which it is attached. I confirm that all information provided is accurate and that I consent to the changes outlined in this amendment. I understand that this amendment is part of the original consent form.
Signature
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Full name *
Amendment date *
Comment
SAVE
Share a copy of this form with
the pet owner
Submit Form
Add Patient Photo
Select a photo
CANCEL
SAVE PHOTO
Required fields.
The following
*
required
fields need to be completed:
OK
