Office use Date: Nurse:
New Client / Pet Form
All personal information will be treated with complete professional confidentiality.

Your Details:

Mr/Mrs/Ms/Miss Surname:______________________First Name:_________________

Address:_________________________________________Suburb:_________________


HomePhone:_____________WorkPhone:______________Mobile:__________________


E-mail address______________________________________________________________

How did you hear about us? Local paper Pet Shop Saw the clinic

Yellow Pages Referred by: _______________________________

Other________________________________________________________

Your Pet’s Details:


Does your pet have PET HEALTH INSURANCE? Yes / No Insurer:__________________

Name: _______________________Breed______________________________________


Age or date of birth: ___________ Sex: _____________ De - Sexed: Yes / No

Colour: ______________________ Last Vaccination date_______________________


Microchip number:__________________________________________________________

Dental Care
Do you brush your pet’s teeth? Yes / No
Date of last dental cleaning at a vet clinic?_______________

Heartworm Prevention
When was the last time your pet received heartworm prevention? Date:___________
What brand of heartworm prevention do you use?____________________________


John the Vet, Bentleigh
Dedicated to improving the quality of life of all creatures great and small.