New Patient Form

Option 1

Complete Online

Complete and submit the online form below.

Option 2

Download & Complete

Download and complete the form and submit online.

Download & Submit Form

Option 3

Complete on Arrival

If you prefer, fill out the form when you get to our hospital.

New Patient Form

Owner Information

Owner First Name *

Owner Last Name *

Email *

Address *

City *

Postal Code *

Province

Home Phone

Work Phone

Cell Phone

Secondary Owner / Authorized Agent Name *

Phone *

Patient Information

Pet Name *

Species *

Breed / Other Species *

Colour *

Birth Date / Age *

Weight *

Vaccination Status *

Gender *

Spayed or Neutered? *

Notes *

Primary Veterinarian Information

Regular Veterinary Hospital

Phone *

Regular Veterinarian *

This pet is currently fed what brand of food? (Canned, Dry, Homemade) *

What dental home care is provided (brushing, water additive, toy...) and how often? *

Does your pet have a drug allergies or sensitivities? Y/N Please explain: *

Does your pet have any food allergies or sensitivities? Y/N Please explain: *

Does your pet have difficulty with anesthesia? Y/N Please explain: *

Does your pet have any ongoing medical or surgical problems? Y/N Please explain: *

Vaccination Status - When was your pet last vaccinated and against which infections? *

Is your pet on any prescribed or over the counter medications? Y/N Please explain: *

Do you have pet insurance? Y/N If so, which plan? *

Hale Veterinary Clinic Social Media Release Form

We use social media platforms to increase awareness of dental diseases in pets so more pets can receive the appropriate dental treatments they need. It is also a great way to showcase our team and the patient care we provide. In order to publish photos and radiographs of your pet, we kindly ask you to select your preference and digitally sign the release form. Regardless of your choices, confidentiality is assured and your personal information will not be disclosed.

Hale Veterinary Clinic had my permission to use:

Please select one: *

My pet's intra-oral photos, radiographs, and photos of my pet's face.

My pet's intra-oral photos and radiographs only.

Do not use any of my pet's images.

Please select one: *

My pet's name.

Do not use my pet's name.

I hereby grant permission to Hale Veterinary Clinic to use images of my pet on Facebook, Instagram, and other social media platforms.

I waive any right to royalties or other compensation arising or related to the use of my pet’s images or recording. I also understand that this material may be used in diverse educational and promotional settings.

By signing this release, I understand this permission signifies that photographic or video recordings of my pet may be electronically displayed via the Internet.

By signing this form, I acknowledge that I have completely read and fully understand the above
release and agree to be bound thereby. I hereby release any and all claims against any person or
organization utilizing this material for promotional purposes.

Signature *

Date *

By submitting this form, I hereby authorize Hale Veterinary Clinic to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Barrhaven Veterinary Hospital.

Spam Blocker

Accepting New Referrals

Hale Veterinary Clinic is accepting new referrals! If you are a veterinarian looking to refer a patient, please fill out our referral form. If you are a client whose pet has already been referred to us, learn more about what to expect at your pet's appointment.

Refer A Patient Client Information