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New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your co-operation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Work Phone
Phone TypePhone Number
Other Number
Phone TypePhone Number
E-Mail Address :
Other Family/Household Members
First Name
Last Name
Other Family/Household Members
First Name
Last Name
How did you hear about our clinic?

Cat's Name (required)

Age: Years, Months

Breed:

Sex: (required)
Male
Female
Is your cat (required)
Neutered
Spayed
Intact
Colour & Markings

Does your cat have a microchip or ear tattoo for identification? (required)
Yes
No
Not Sure
If Yes, Number?

Where did you get your cat?

Name of Former Veterinary Practice (required)

Has your cat ever had a blood test for the Feline Leukemia Virus or Feline Immunodeficiency Virus? (required)
Yes
No
Not Sure
If so, was the test
positive
negative
Are you cat's vaccines current? (required) :
What for?
Panleukopenia (feline distemper)
Rhinotracheitis/Calicivirus (upper respiratory diseases)
Feline Leukemia Virus (recommended for outdoor cats)
Rabies (recommended for outdoor cats)
Feline Infectious Peritonitus
Chlamydia (upper respiratory disease)
Feline Immunodeficiency Virus
Do youhave Pet Health Insurance?
Yes
No
If so, with what company?

What brand of food do you feed your cat? (required)

Is your cat's lifestyle: (required)
Indoor Only
Indoor + Outdoor only when supervised or on a leash
Indoor + Outdoor on a deck or balcony
Indoor/Outdoor
Outdoor
What type of dental care do you provide for your cat at home? (required)
Dental Diet
Dental Treats
Brushing
Rinsing
Nothing
Interested in learning how
Do you have children living at home? (required)
Yes
Part Time
No
Please list any additional pets here

Does your kitty sleep with you? (required)
Yes, Always
Sometimes
Has own spot
Not Allowed
Please list any significant medical history here

Please list any medications your cat is taking here

Reasons or conditions that prompted your visit?

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Pacific Cat Clinic and that charges are due and payable at the time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance charge. Any balance that I leave unpaid will be forwarded to a collection agency.
I have read this statement and -
I Agree
I Disagree


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