Shamrock Vet Clinic

1896 Guthrie Rd
Comox, BC V9M 3X7

(250)339-2026

shamrockvetclinic.ca

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 cooperation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)

Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Date of Birth

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pet's vaccines current?
Does your pet have medical records at another veterinary practice?
Yes
No


May we request a transfer of records?
Yes
No


Name of former veterinary practice:

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

Special requests or conditions?

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 Shamrock Veterinary Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance.
I have read this statement and -
I Agree
I Disagree


How did you become aware of our hospital?
Hospital Sign
Word of mouth
Website
Facebook
Yellow Pages
Other


If you were referred, whom may we thank?


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