New Client Information Form

Welcome to Killarney Cat Hospital! Please complete this form when you have a moment.

Owner's Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Cat's Name *

Age / Colour/ Breed *

Do you have pet insurance? *

• Yes
• No

What is the name of your previous vet(s)?

Is there anything else you would like us to know about your cat? *

Are there any other humans in the household? *

• Yes
• No

Please list their names along with your relationship: *

Are there any other pets the household? *

• Yes
• No

Please list the other pets here: *

Include name, species, breed, age and any other relevant information.

How did you hear about us? *

• Google
• Drive by
• Friend/ Family (specify below)
• Another Vet (specify below)
• Facebook
• A rescue
• Other Internet
• Other (specify below)

Please specify: *

name of the friend, family, vet clinic or other who referred you to our clinic...

Canada’s Anti-Spam Legislation (CASL) requires that we receive your consent to continue to communicate with you electronically via email, text or social media. We use electronic communication to inform you of upcoming clinic events and special promotions, provide pet health reminders and medical information and also offer appointment requests and reminders electronically. We hope that you find every message you receive from us relevant to your pet and of interest to you but if ever you wish to discontinue receiving emails you need simply to let us know and we will remove you from the list. *

• I consent
• I do NOT consent

Payment is expected at the time services are rendered. We accept CASH/VISA/MASTER CARD/DEBIT CARD. We do not offer payment plans. We have a 3rd party financial company option if financing is required. We make every effort to make sure all fees are fair and reasonable, and you are encouraged to discuss charges before services are rendered. The doctor or the receptionist will be happy to discuss estimates on all medical and surgical procedures performed. Our fees are available at any time upon request. Please note: Office call/Exam room fees cover more than the time you and your pet spend with your veterinarian. These fees cover your doctor's time spent reviewing and updating your pet’s medical records and history; documenting any current problems; consultation with other professionals or reviewing research and written information when appropriate; directing support staff in the care of your pet, as well as other administration expenses. Follow-up rechecks are usually not included in the originating office/exam/consultation fee. *

• I have read and understood

At Killarney Cat Hospital we respect your right to privacy and will not collect, use or disclose any personal information regarding you or your pet without your consent. The information we seek from you is obtained so that we can provide a high quality of veterinary service and ensure that you are fully aware of our actions. In all cases, we will only disclose personal information about you in circumstances where we believe that it will be beneficial to the continued good health of your pet. I hereby consent to Killarney Cat Hospital collecting and/or using personal information about me and my pet/pets for medical purposes only. *

• I have read and understood

Submit