New Client Form

If you are a new cllient, please fill out the form below. Alternatively download the form and bring it along to your first appointment.

DOWNLOAD FORM

NEW CLIENT REGISTRATION FORM

CLIENT DETAILS

Client Name *

Address *

Phone *

Email Address *

PATIENT DETAILS

Patient Name *

Breed *

Age / DOB *

What sex is your pet? *

Male Female

Is your pet desexed? *

Yes No

What colour is your pet? *

Do you brush your pet’s teeth? *

Yes No

If you brush your pets teeth, how often?

How much does your pet weigh?

REASON FOR REFERRAL

Write your comments here *

Current Medication(s) *

Current Diet *

REFERRING VETERINARIAN DETAILS

Veterinarian Name *

Veterinary Clinic Name *

Phone number(s) *

PLEASE ACKNOWLEDGE

Please note that by signing below you are acknowledging that you will assume responsibility for all charges incurred in the care of this pet. I understand that full payment, in the form of cash, cheque, eftpos or credit card, is to be made at the time of consultation or upon collecting your pet from our hospital. *

I Agree

I agree to return to my usual veterinarian for all other healthcare needs for my pet and agree that I will not return to Auckland Veterinary Dentistry and Oral Surgery or Kohimarama Veterinary Clinic. *

I Agree