New Client Form - Epsom Road Veterinary Clinic

New Client Form

03 9370 1900

Please fill out our New Client Form before your first visit with us. We’re looking forward to seeing you and your pet soon!

New Registration

Primary Owner Details:

Title

First Name *

Surname *

Primary Phone: *

Home Phone:

Work Phone:

Email: *

Address Line 1: *

Address Line 2:

Suburb: *

Postcode:

Co-owner Details:

(If applicable)

Title

First Name

Surname

Primary Phone:

Other Phone:

We send your pet's health reminders via SMS and email. If you would not like to receive reminders please let us know.

Would you like to receive our monthly email newsletter?

Yes

Pet Details:

(if you have more than one pet there is an additional section below)

Pet Name: *

Species: *

eg, Dog, Cat, Other

Breed: *

Sex: *

Male

Female

Colour: *

Age / Date of Birth: *

Microchip:

Yes

If yes, microchip number:

Is your pet desexed?

Yes

Date of Last Vaccination:

Do you administer any parasite treatments at home?

Yes

If yes, name of parasite treatment:

Does your pet have an existing medical condition?

Yes

If yes, name of condition/s:

Is your pet on any medication?

Yes

If yes, type of medication/s:

Have you previously been to a different vet clinic?

Yes

If yes, name of clinic/s?

We love sharing the adventures of our patients and life in a Veterinary practice (who doesn’t like seeing cute pet photos on the internet?).

We will only ever refer to your pets by their first name.
We will never share personal details.
We will show respect and empathy to our patients and clients.

Do you give consent for us to share photos of your pet on our official clinic Facebook and Instagram pages?

I give consent

I do NOT give consent

How did you hear about us?

Passing by

Our website

Facebook

Google

Instagram

Other

Referral /Word of Mouth - If referred, would you mind telling us by whom, so that we can thank them?

Payment Terms:

It is Clinic policy that all accounts are to be paid at the time of service.
We accept Cash, Credit Card and EFTPOS. We are unable to accept payment by cheque.

Client Signature *

Type Name

Date: *

Thank you for choosing us to care for your pets. Our privacy policy can be viewed on our website.

Pet Details 2:

Pet 2 Name:

Pet 2 Species:

eg, Dog, Cat, Other

Pet 2 Breed:

Pet 2 Sex:

Male

Female

Pet 2 Colour:

Pet 2: Age / Date of Birth:

Pet 2 Microchip:

Yes

If yes, microchip number:

Age 2: Is your pet desexed?

Yes

Age 2: Date of Last Vaccination:

Age 2: Do you administer any parasite treatments at home?

Yes

Pet 2: If yes, name of parasite treatment:

Pet 2: Does your pet have an existing medical condition?

Yes

Pet 2: If yes, name of condition/s:

Pet 2: Have you previously been to a different vet clinic?

Yes

Pet 2: If yes, name of clinic/s?

Pet Details 3:

Pet 3 Name:

Pet 3 Species:

eg, Dog, Cat, Other

Pet 3 Breed:

Pet 3 Sex:

Male

Female

Pet 3 Colour:

Pet 3 Age / Date of Birth:

Pet 3 Microchip:

Yes

Pet 3: If yes, microchip number:

Pet 3: Is your pet desexed?

Yes

Pet 3: Date of Last Vaccination:

Pet 3: Do you administer any parasite treatments at home?

Yes

Pet 3: If yes, name of parasite treatment:

Pet 3: Does your pet have an existing medical condition?

Yes

Pet 3: If yes, name of condition/s:

Pet 3: Have you previously been to a different vet clinic?

Yes

Pet 3: If yes, name of clinic/s?

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What Our Clients Say

Testimonials

“Thank-you so much for all your help and support with Molly and Fox (Husky’s). I have been coming to see you for almost 6 years and I have only ever had the best of care.”

Kim M.

“One of the best vet experiences we ever had. They are so friendly and take their time to consult and answer all the questions we have.”

Min P.

Leave a Review

“Thank you for looking after my little terrors for me. They got neutered, the vet and staff were very lovely to deal with and communicated everything well to me. I would highly recommend them. ?

Nelson G.

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Email Address*

First Name

Visit Us

156 Epsom Road,
Ascot Vale
VIC 3032

Google Maps

Opening Hours

Monday – Friday: 8:00am – 6:00pm
Saturday: 9:00am – 12:00pm
Sunday: Closed

Appointments

03 9370 1900

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