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New Client Intake Form

Welcome and thank you for your interest in receiving pet care at Bay Regional Veterinary Hospital.
The information in this form will help us create your profile and identify your current concerns. We
will follow up within 48 hours to schedule your first visit.

If this is an emergency, call (613) 962-4891for direct assistance

New Client Form

Owner Information

Full Name(Required)

Co-Owner Full Name

Phone(Required)

Email(Required)

How did you hear about us?(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Pet Information

Pet's Name(Required)

Breed

Species(Required)

Colour

Sex(Required)

Date of birth/Age

Spayed/Neutered?(Required)

Yes

Unsure

Date of last vaccines (if applicable)

What vaccines were given? (if applicable)

Does your pet have/had a medical condition?

Is your pet on any medication or supplements?

Does your pet have any allergies or drug reactions?

Previous Veterinary Clinic(Required)

Add another pet?(Required)

Yes

Pet's Name(Required)

Breed

Species(Required)

Colour

Sex(Required)

Date of birth/Age

Spayed/Neutered?(Required)

Yes

Unsure

Date of last vaccines (if applicable)

What vaccines were given? (if applicable)

Is your pet on any medication or supplements?

Does your pet have/had a medical condition?

Does your pet have any allergies or drug reactions?

Additional notes about your pet

Pet Photo Consent – Website

I hereby give Bay Regional Veterinary Hospital permission to take photographs and videos of me and my pet for the purpose of posting on their social media (Facebook, Instagram)

Pet Photo Consent – Social Media

I hereby give Bay Regional Veterinary Hospital permission to take photographs and videos of me and my pet for the purpose of posting on their practice website.

Consent Signature (Your Name)

If you give consent to the above, please provide your name and pet’s name so that we can appropriately credit you and your pet!

Consent Signature: Pet's Name

Call:
(613) 962-4891

Address:
437 Bleecker Ave, Belleville, ON K8N 3W2

Hours

Mon-Fri: 8AM - 5PM
Sat, Sun, Holidays: CLOSED

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