613-323-3000
contact@hospicevet.com
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Client Registration Form
Client Registration Form
How did you hear about us?
Date you would like the appointment?
(yyyy/mm/dd) (required)
Time you would like the appointment?
(required)
08:00
08:30
09:00
09:30
10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
16:00
16:30
17:00
17:30
18:00
18:30
19:00
19:30
20:00
20:30
21:00
21:30
22:00
22:30
23:00
Primary Owner's First & Last Name (required)
Other Family Names & Relationships (spouse, child, etc.)
Children Ages (if applicable)
Other Pets in the Household
Address (required)
City (required)
Province (required) (please select one)
Ontario
Quebec
Postal Code (required)
Home Phone Number (required)
Cell Phone Number
Work Phone Number
Your Email (required)
Veterinarian Clinic(s) (required)
Does your pet have health insurance?
Yes
No
(If yes) Name of Insurance Company
Pet Name (required)
Dog or cat?
Dog
Cat
Breed (required)
Colour (required)
Pets Age (required)
Sex
Male
Female
Spayed / Neutered
Yes
No
Pets Weight (kg)
After care wishes should your pet be euthanized (please select one)
Please select one if applicable
Home burial
Group Cremation with no ash return
Semi Private Cremation with ash return
Private Cremation with ash return
A few words about what has been going on with your pet.