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 (male)
Spayed (female)
Intact


Are your pets vaccines current? (Check if yes)
Do you have your pets medical records? (Check if yes)
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 (check if yes)
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here


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