New Patient Form | PEI Veterinary Walk-in & Urgent Care

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58 Macleod Cres a, Charlottetown, PE C1E 3K2, Canada

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New Patient Form

Please complete the form below as fully as possible prior to pet’s first appointment which will help expedite the registration process and give us valuable insight in providing the best possible care for a pet.

Owner’s First Name*

Owner’s Last Name*

Co-Owner’s First Name*

Co-Owner’s Last Name*

Phone number

Street Address*

Address Line 2

State / Province / Region*

City*

ZIP / Postal Code*

Country*

Mobile number

Email*

How did you find out about our practice?*

Clinic Location
Personal Referral
Internet Search/Website

Yellow Pages
Clinic-Sign
Newspaper / Print Media

Other

If Other, please specify:

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

Pet’s Name*

Species*

Breed (if known)

or if other species

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex*

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

What food does your pet eat?

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?

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

I agree to receive text messages from PEI Veterinary Walk-in & Urgent Care regarding my inquiry. Message and data rates may apply. See our Privacy Policy for more details.

58 Macleod Cres a, Charlottetown, PE C1E 3K2, Canada

info@peiurgentcare.ca

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