New Pet Information Form

Owner/Caregiver’s Details
Name:: First Name:
Last Name:
Address:: Line 1:
Line 2:
City:
Country:
State:
Postal Code:
Email:
Phone:
How did you find out about HIGHlands Veterinary Hospital?:
If you were referred by someone else, what is their name?:
Statement of Ownership - By checking below you certify that you are the owner and/or agent of the above animal and have authorisation to consent to treatment if and when it is needed.:: I Agree
Pet Information
Pet's name:
Breed of Pet:
Age of pet:
Date of birth:
Colour of pet:
Sex of Pet:: MaleFemale
Is your pet desexed?:: YesNo
Where or from whom did you get your pet?:
What types of food and treats do you give your pet?:
Does your pet have any known medical conditions?:
Please check any of the following that apply to your pet:: There are other animals in the home.My pet is on medication, including supplements.My pet has contact to other animals outside the home.My pet has had dental work, cleanings or extractions.
Please include any other information that you'd like to provide:
What is your pet's microchip number?:
Type and date of last vaccination (if you know):
Do you have any concerns about your pet?:
Pet insurance details and policy number (if applicable):
Name and location of previous vet (if applicable):