New Client Registration Form – Eagle Ridge Animal and Bird Hospital in Coquitlam, BC

Owner Information

Owner's Name(s)*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone*

Mobile Phone

Work Phone

Which phone number would you like to be the primary number in our system?*

Home
Mobile
Work

Email Address*

Enter Email Confirm Email

How did you find out about our practice?

If Personal Referral, is there someone we can thank for this referral?

Have you already scheduled your first visit at our practice?*

Yes
No (If you wish to schedule an appointment, please use our Make an Appointment form)

If yes, please provide the date and time below.

Please use this area to give us any other relevant information about yourself or your family.

Photographic Consent*

We want your pet(s) to be Facebook Famous! But we need your permission first. We may use photos and/or video of your pet(s) for educational or marketing purposes (including but not limited to print, video, web, and social media).

Yes, I give my consent.
No, I do not consent.

Pet Information

Pet's Name(s)*

Species*

or if other species / multiple species

Breed*

Sex*

Colour*

Date of Birth or Age (approximate if not known)*

Special Identification (tattoo, microchip, etc.)

Previous Veterinary Practice (if any)

Date of last vaccines (if known)

What vaccines were given at this time?

Is your pet on any medications or supplements?

Yes
No

If yes, please list the medication or supplement.

What food does your pet eat? (ie. brand, wet and/or dry)

Does your pet have allergies or drug reactions?

Yes
No

If yes, please list the allergies and reactions.

Are there any current or past medical conditions of which we should be aware of?

Yes
No

If yes, please comment on the condition(s) and indicate if they are current or past conditions.

Please use the following box to give us any other relevant information about your pet.

Captcha

Owner Information

Pet Information

Contact Us

Hours Of Operation

Directions