New Client Form

New Client Intake Form

Welcome, and thank you for your interest in receiving pet care at Mount Joy Animal Clinic.

The information in this form will help speed up the process of creating your profile and will identify your current
pet concerns. We will follow up with you to book an appointment.

Pleasecall usfor any questions or technical issues with this form.

Owner Information

Full Name(Required)

Co-Owner Full Name

Please list all individuals who are authorized to make medical decisions regarding the patient

First name, last name, relationship with client

Phone (Cell)(Required)

Phone (Work)

Email(Required)

Which is your preferred mode of contact(Required)

Cell

Work

Other

Address(Required)

Street Address Address Line 2 City Province Postal Code

Pet Information

Pet's Name(Required)

Breed(Required)

Species(Required)

Colour(Required)

Sex

Male

Female

Date of birth/Age(Required)

Indoor only? (cats)

Yes

Previous Veterinary practice (if any)

Previous Veterinarian (if Any)

How did you hear about us?

Date of last vaccines (if applicable)

What vaccines were given? (if applicable)

Do you have copies of all latest vaccine certificates?

Yes

If so, please bring them with you to your appointment

Which medication/supplemnts is your pet taking? Please list:

Does your pet have/had a medical condition?

What food does your pet eat? (brand & amount)

Does your pet get human food? If so, which food?

Does your pet have any allergies or drug reactions?

Microchipped?(Required)

Yes

If no, do you want it to be done during the visit?

Yes

Main Concern for the Visit

Please indicate your main concerns for the the visit and how long you’ve noticed the condition for.

When was the last time you remember your pet's health being normal?

Pet Health Survey

How is their behavior?(Required)

Lethargic

Normal

Hyperactive

How is their eating?(Required)

Decreased

Normal

Increased

How is their drinking?(Required)

Decreased

Normal

Increased

How is their urination?

Decreased

Normal

Increased

How is their bowel movement?

Normal

Abnormal

When was their last bowel movement?

Mouth/teeth: Are any of the following symptoms present?

Check all that apply

Bleeding Mouth/Teeth

Broken Teeth

Loose Teeth

Growths in Mouth

Nose: Are any of the following symptoms present

Check all that apply

Nasal Discharge

Eyes: Are any of the following symptoms present?

Check all that apply

Redness

Swollen

Discharge

Inflamed

If yes, left, right or both eyes?

Ears: Are any of the following symptoms present?

Check all that apply

Redness

Swollen

Discharge

Inflamed

If yes, left, right or both ears?

Breathing: Are any of the following symptoms present?

Check all that apply

Rapid Breathing

Breathing Difficulty

Coughing

Gastrointestinal: Are any of the following symptoms present?

Check all that apply

Excessive Gas

Vomiting

If vomiting, frequency, and contents?

Genitals: Are any of the following symptoms present?

Check all that apply

Discharge

Blood in Urine

If blood in urine, when?

Coat/Skin: Are any of the following symptoms present?

Check all that apply

Licking

Scratching

Masses

Lymph Nodes Swollen

If masses, where?

Legs/Paws: Are any of the following symptoms present?

Check all that apply

Limping

Broken Nails

Ingrown Nails

If limping, for how long?

Any other concerns?

What language do you prefer the doctor speak?

English

Mandarin

Cantonese

Pet Photo Consent – Social Media

I hereby give Mount Joy Animal Clinic permission to take photographs of my pet for the purpose of posting on their social media (Facebook, Instagram)

Pet Photo Consent – Website

I hereby give Mount Joy Animal Clinic permission to take photographs and videos my pet for the purpose of featuring 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

New Client Intake Form

New Client Form

Owner Information

Pet Information

Pet Health Survey

Learn about what to expect before your visit