Store
Hours
Location
Contact
Owner's Name (required)
Co-Owner (if applicable)
Address (required)
City (required)
Phone number
Work phone number
Cellular phone number
By providing my email address below, I am agreeing that Quinte Animal Hospital employees are permitted to send emails to the below address in regards to my pets.
I can opt out of receiving emails at any time by contacting the hospital by phone or email. This email address may be used in correspondence relating to pet health insurance, news, updates etc.
Email Address Would you like access to our web store?—Please choose an option—YesNo
Are you a member of the Canadian Armed Forces?—Please choose an option—YesNo Valid ID will be required for military discount
How Did You Find Out About Our Hospital? (Please select / complete one option below)
—Please choose an option—IndividualInternetYellow PagesHospital SignMFRc / Welcome BookFacebookOther
Please enter their name so we can send a "thank you"
Which Site?
Other:
What Will Our Relationship Be? (Please Select One Option) —Please choose an option—Regular VeterinarianHere for an Emergency OnlySecond OpinionOther
If Other, please fill out:
Name:
Phone Number:
DogCat
Pet Name: Breed: Gender: Spayed / Neutered? Colour: Age / Date of Birth:
MaleFemale YesNo
Remove PetAdd Pet
This information is obtained in confidence and is intended for use only by Quinte Animal Hospital. Any other distribution, copying or disclosure is strictly prohibited. The contents of this document may also be subject to privilege and all rights to that privilege are expressly claimed and not waived.
We want to make your pet famous! Do we have your permission to share your pet's photo and/or story online? Images may also be used for educational or advertising purposes.YesNo
By submitting this New Clients Form, I agree that I am the legal owner of the pet(s) listed above and that all information is true.
