Intake Form

Owner Name (required)
Address (required)
Town (required)
Postal Code (required)
Home Phone (required)
Owner Email (required)
Cell phone
Work phone
Spouse Name
Spouse Phone
Other Phone
How did you hear about us?
Pet's Name (required)
Tattoo number or Microchip number.
Sex MaleFemale
Spayed/Neutered? YesNo
Birth date / age
Is your pet up to date on vaccines (if applicable) YesNo
Last vaccine date
Are there other pets in the home (please list)?
Is your pet on a special diet or medications (please list)?
What do you feed your pet?
Do you feed your pet human foods or bones?
Does your pet have any known drug or food in-tolerances or allergies? YesNo
Does your pet travel outside of Alberta? YesNo
Does your pet go to a groomer, daycare, off leash, kennel or to agility classes? YesNo
Does your pet live in or visit a rural area? YesNo
Does your pet hunt or eat uncooked or raw foods? YesNo
Is your pet exposed to children? YesNo
Where does your pet primarily live? IndoorsOutdoorsBoth
Please list known medical conditions
To serve you better, please let us know if your pet has been to another animal hospital.
Hospital Name
Do you wish us to contact your previous veterinarian for medical information? YesNo
Can we send you information by mail or email about veterinary topics or wellness tips for your pet(s)? YesNo
Please indicate if you have concerns or your pet has changes in:
Drinking YesNo
Urination YesNo
Appetite YesNo
Weight YesNo
Skin/hair coat YesNo
Body Odour YesNo
Mobility YesNo
Breathing YesNo
Digestion YesNo
Senses (hearing, vision etc) YesNo
Behaviour YesNo
Lumps/bumps/masses/growths YesNo
Will you need an appointment at this time? YesNo
Additional Comments