Client's Name *

First Name

Last Name

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's Primary Phone Number (Home or Cell) *

(###)

###

####

Client's Secondary Phone Number (work or cell)

(###)

###

####

Client's Alternate Phone Number (if have home/cell/work numbers)

(###)

###

####

Patient Name *

First Name

Last Name

Patient Birth Date *

MM

DD

YYYY

Would you like to make an appointment for your pet? *

YES

Not at this time.

Photo/Media Consent *

Do you give consent to having your happy and comfortable pet’s photo/video taken while in hospital? This photo/video would be use for educational and/or on social media.

YES

NO

Veterinary Medical History *

Is your pet registered with any other veterinary hospitals?

YES

NO

Do you consent to us calling your previous veterinary hospital listed above to obtain a copy of your pet's medical records? *

Having your pet's complete medical history will help to ensure we can offer the best care possible for your beloved pet.

YES

NO

myVETstore *

Do you have myVETstore account registered with another veterinary hospital?

YES

NO

Communication Consent *

I consent to Heritage Veterinary Hospital communication with me via phone, email and/or text messaging at the provided phone number and email address.