Dale Veterinary Clinic

121 Toronto Rd
Port Hope, ON L1A 3S6

(905)885-9577

www.daleveterinaryclinic.com

New Client Check In

 

No one knows your pet quite like you do. At Dale Veterinary Clinic we strive to build a personal connection with you and your pet. We are a full service clinic located in the heart of Port Hope. 

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

 

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)

Male
Female


Neutered/Spayed

Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?

Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here


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