Dauphin Vet Clinic

PO Box 556
Dauphin, MB R7N 2V4

(204)638-3044

www.dauphinvetclinic.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client

Name & Email (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Mailing Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone
Phone TypePhone Number
How did you here about us? (required) :
Who referred you? (If applicable)

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :
Breed: (required)

Color (required)

Sex: (required)
Male
Female


Neutered/Spayed (required)
Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Dauphin Vet Clinic and Ste. Rose Vet Clinic that charges are due and payable at the time of service, unless other arrangements are made in advance. We accept many forms of payment including cash, cheque, credit and debit as well as e-transfer. We can also take payments over the phone. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 2%. Any balance that I leave unpaid will be forwarded to Dauphin Vet Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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