New Patient Registration

Owner's Name (required)

Co-Owner (if applicable)

Address (required)

City (required)

Phone number

Work phone number

Cellular phone number

Informed Consent for Email Contact:

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?

Are you a member of the Canadian Armed Forces?
Valid ID will be required for military discount

How Did You Find Out About Our Hospital? (Please select / complete one option below)

Please enter their name so we can send a "thank you"

Which Site?

Other:

What Will Our Relationship Be? (Please Select One Option)

If Other, please fill out:

Emergency Contact

Name:

Phone Number:

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.

Photo Release

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.

71 Murphy St, Trenton, ON – 613.392.8900

New Patient Registration

Informed Consent for Email Contact:

Emergency Contact

Patient Information

Photo Release