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New Client Registration Form

Thank you for considering Wellington Veterinary Clinic 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 call the clinic at 905-294-1900 to register.

You will be asked to select a password, which must be at least 4 characters in length. Ensure this is something you will easily remember. This password will be needed to access client only areas of our site.


Client Information
Owner´s Name
Salutation
*First Name:
*Last Name:
*New Password:
*Confirm Password:
Co-owner´s Name:
Salutation:
First Name:
Last Name:
Address
*Country: Canada
*Province:
*City/Town:
*Address 1:
Address 2:
*Postal Code:
*Day-Time Phone: ( ) -
*Evening Phone: ( ) -
Mobile Phone: ( ) -
*E-Mail:
*Confirm E-Mail:
Co-Owner´s Contact Information
Day-Time Phone: ( ) -
How did you find out about our practice?
Clinic Location Website Yellow Pages
Clinic Sign Newspaper Personal Referral
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

  Pet Information
*Pet´s Name:
*Species:   or if other species:
Breed (If Known):
Colour:
Date of Birth:
Special Identification
(Tattoo, Microchip, etc):
Sex:  
Previous Veterinary Practice (If Any):
Previous Veterinarian (If Any):
Date of Last Vaccines (if known, yyyy/mm/dd)
What Vaccines were given at this Time:
Is your Pet on any Medication or Supplement?
Yes
No
If Yes, Please List the Medication or Supplement:
What food does your pet eat?
Please type answer here:
Does your Pet have Allergies or Drug Reactions?
Yes
No
Are there any Current or Past Medical Conditions of which we should be Aware?
Yes
No
If Yes, Please Comment on the Condition(s) and Indicate if they are Current or Past Conditions:
Please use the following box to give us any other relevant information about your pet:

Please enter the validation code to the right to complete registration. [javascript must be enabled]
 

 

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September 4, 2010

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    8185 McCowan Road
    Markham, Ontario
    L3P 3J3

    Ph: 905-294-1900
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