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ABOUT
About Our Clinic
OUR TEAM
Dr. Ashley Bernauer
Dr. Graeme Linton
Dr. Sheila Finch
Dr. Thisuri Eagalle
Dr. Nancy Louis
Dr. Jared Watson
Dr. Hayley Doody
Dr. Tara Westworth
Sheena
Joyce
Shayla
Mya
Megan
Mykena
Brandy
Jolene
Kevin
Kim
Ezrah
Nicola
Barb R
Sage
Barb J
Colleen
Kirstin
Rachel
Lynette
Hanna
Ashley W
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Integrative Therapy Consent Form
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New Patient Form
Help us get to know you and your pet!
Client Info
Client First Name
Client Email
Client Last Name
Client Phone Number
Client Address
Preferred Method of Contact
Phone
Email
Additional contact you wish to have on your file. Please include name, phone number, and relationship to you.
Patient Info
Patient Name
Age
Patient Date of Birth
Sex
Male
Male Neutered
Female
Female Spayed
Pet Insurance Provider
Species
Dog
Cat
Other
Breed
Colour
Previous Veterinary Hospital
Pet Insurance Number
I give permission for my pet to be photographed and/or videoed for any lawful purposes, including publicity, illustration, advertising and website content.
Yes
No
Diet
What do you feed your pet?
Kibble/Dry
Canned/Wet
Commercial Raw
Homemade Raw
Freeze Dried Raw
Homemade Cooked
Gently Cooked
Other
Pet Food Brand
Pet Food Formula
Does you pet have any known allergies?
How many meals per day do you feed your pet?
How much do you feed per meal?
Do you feed your dog anything in addition to their meals? Example: Treats, Veggies, Toppers etc. If so, how much per day?
Activity Level
Sedentary - Spends most of the day indoors/little to no play
Low - Less than 1 hour of activity or play per day
Medium - 1-3 hours of activity or play per day
High - Over 3 hours of activity outside per day
Medical Information
Please bring any medications or supplements your pet is on to your first appointment.
Please select all that apply to your pets temperament
Human Reactive
Dog Reactive
Anxious/Nervous
Unsure of New People
Needs Space
Friendly
Calm
Excitable
Food Motivated
Toy Motivated
Other
Does your pet have any known medical conditions?
Please list any medications your pet is on. Please include the dose.
Please list any supplements your pet is on. Please include the brand & dose.
Do you believe your pet would benifit from receiving calming medication prior to appointments?
Yes
No
Is there anything else you feel is important for us to know about you or your pet that you would like to share?
I accept terms & conditions. I consent to the use and storage of my information in accordance with the terms and conditions detailed in the QBAH Privacy Statement in the link below
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