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New Client Intake Form

Welcome and thank you for your interest in receiving pet care at Moira Veterinary Clinic.
The information in this form will help us create your profile and identify your current concerns.

We will follow up within 72 hours to schedule your first visit.

If this is an emergency, pleasecall usfor assistance

New Client: Down Payment Notice:
We require a $120 down payment to hold your spot and book an appointment, this will be deducted from your final bill at your first appointment. This form will not require payment, our team will follow-up to confirm booking and any further details.

New Client Form

Owner Information

Full Name(Required)

Co-Owner Full Name

Phone(Required)

Email(Required)

How did you hear about us?(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Pet Information

Pet's Name(Required)

Breed

Species(Required)

Colour

Sex(Required)

Date of birth/Age

Spayed/Neutered?(Required)

Yes

No

Unsure

Date of last vaccines (if applicable)

What vaccines were given? (if applicable)

Does your pet have/had a medical condition?

Is your pet on any medication or supplements?

Does your pet have any allergies or drug reactions?

Previous Veterinary Clinic(Required)

Add another pet?(Required)

Yes

No

Pet's Name(Required)

Breed

Species(Required)

Colour

Sex(Required)

Date of birth/Age

Spayed/Neutered?(Required)

Yes

No

Unsure

Date of last vaccines (if applicable)

What vaccines were given? (if applicable)

Is your pet on any medication or supplements?

Does your pet have/had a medical condition?

Does your pet have any allergies or drug reactions?

Additional notes about your pet

Pet Photo Consent – Website

I hereby give Moira Veterinary Clinic permission to take photographs and videos of me and my pet for the purpose of posting on their social media (Facebook, Instagram)

Pet Photo Consent – Social Media

I hereby give Moira Veterinary Clinic permission to take photographs and videos of me and my pet for the purpose of posting 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

Call:
(613) 779-6770

Email:
info@moiravetclinic.ca

Address:
44B Moira St W, Belleville, ON K8P 1S3

Hours

Mon-Fri: 9AM - 5PM
Sat, Sun, Holidays: CLOSED

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