New Client Application Form – Main Street Veterinary Services

Owner's Name

Name*

First Last

Co-owner's Name & Contact #

Name

First Last

Primary phone number*

The best telephone # for us to contact you

Primary phone type

mobile phone
land line

Secondary phone number

The second best phone # for us to reach some one at

Secondary phone type

mobile phone
land line

Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Enter Email Confirm Email

How did you find out about our practice?*

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

Referring vet clinic*

At Main Street Veterinary Services we offer a wide variety of holistic or non-conventional medications and therapies in additional to conventional medicine. The College of Veterinarians of Ontario considers holistic therapies and holistic medications to be non-conventional due to lack of scientific validation. Our Veterinarians integrate all available modalities and diagnostic procedures, conventional and holistic, in the care of our patients. By acknowledging below you are indicating you are aware both holistic and conventional therapies may be offered as treatment options during your appointment at Main Street Vet Services and you consent to the use of both in the care of you pet(s).*

I understand the above statement

May we contact your previous vet clinic for your pet's health records? Having your pet’s medical history available prior to the first appointment allows our veterinarian to have a more complete understanding of their health status.*

Yes
No

Please list all previous veterinary practices - provide name, phone and location if possible*

Pet Information

Pet's Name*

Species*

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

What is your primary concern or need for services with this pet? Please provide as much detail as possible*

Has your pet been diagnosed with any medical conditions?

Yes
No

If yes, please explain.*

Is your pet on any medications or supplements?

Yes
No

If yes, please list type and brand

What food does your pet eat?

Does your pet have allergies?

Yes
No

If Yes, please list the allergies and reactions seen.

When you have successfully completed this from, the browser will flash up a new window with a confirmation that you have successfully submitted this form and that an email of your answers to this questionnaire has been sent to you. If you do not receive this email, you have not successfully completed this from.*

Acknowledged