PERSONAL DETAILS Name * First Name Last Name Phone number (that we can contact you on today) Email address * Home address * How did you find out about us? * I live local to the clinic Recommendation from past/present client Referral from another vet Google search Yellow pages Road sign Other YOUR PET'S DETAILS Pet's name * Sex * Male Female Age/DOB * Breed * Colour * Is your pet neutered? * Yes No Not relevant for my pet Is your pet microchipped? * Yes No Not relevant for my pet Microchip number (if your pet has one) Previous veterinary clinic (for requesting previous clinical histories) History eg. vaccination dates PET INSURANCE Do you pet have insurance? * Yes No Which insurance company? ELECTRONIC CONSENT Please note: We do not carry accounts for any of our veterinary products or services and require full payment to be made at the time of consultation or upon collecting your animal from our hospital. Signing below is an acknowledgment of this condition. * Electronic signature required Yes No Thank You!We appreciate you taking the time to fill out the form. Your details have been submitted, and we’ll be in touch soon. If you need further help, please call reception on 09 521 1457.RegardsThe Kohi Vet Team New Client Registration
