New Client Form - Gateway Veterinary Services

Registration

Name of Owner *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone *

Alternate Phone

Your cell phone will be utilized to update you on patient status, appointment reminders, and to contact you directly in regards to your pet/livestock.

Email *

Spouse/Partner

Phone

Email

Preferred Contact Method *

Phone
Email

How did you hear about us? *

Who referred you, we'd love to thank them!

If Other, please explain

Patient Information

Pet's Name *

Species *

Cat
Dog
Other

If Other, please elaborate

Age *

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed *

Colour *

List any known allergies

Other pets in the household? *

Yes
No

Would you like to add information for another pet? *

Yes
No

Pet's Name *

Species *

Cat
Dog
Other

If Other, please elaborate

Age *

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed *

Colour *

List any known allergies

Would you like to add information for another pet? *

Yes
No

Pet's Name *

Species *

Cat
Dog
Other

If Other, please elaborate

Age *

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed *

Colour *

List any known allergies

Please upload any of your pet's records that you may have

Click or drag files to this area to upload. You can upload up to 5 files.

Do you have pet insurance? *

Yes
No

If yes, please let us know which company

Former Veterinarian Name/Hospital

Former Veterinarian's Phone Number

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospital treatment. *

I have read and agree

I hereby authorize the release of my pet’s medical records to another facility (boarding/daycare, urgent care facility, etc.), should they be requested. *

Yes
No

Signature of Pet Owner *

Date *

Registration

Patient Information

Authorization

Book an appointment online from any device!

Click the button below to get started. We look forward to seeing you and your family soon!