New Client Form — Capitol Hill Animal Hospital

If you are a new client and have an appointment already booked with us, please fill out the form below so we have as much information as possible and can create a client file for you and your pet.
You will need to call the clinic if you would like to book an appointment.

Dr. Chow is no longer accepting new dog and cat patients.
Dr. Meyer, Dr. Blondel, and Dr. Upjohn are all currently accepting new patients.

Do you have an appointment booked?

Yes

Appointment Date

If yes, please note the date of your booked appointment

YYYY

Owner Information

Owner 1

First Name

Last Name

Owner 2

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Owner 1 Phone Number

(###)

###

####

Owner 2 Phone Number

(###)

###

####

Alternate Phone Number

(###)

###

####

We will be able to send emails for upcoming appointments and vaccination reminders.

How did you find out about our clinic?

Clinic Location

Personal Referral

Social Media

Internet Search / Website

Newspaper / Print Media

Other

If other, please specify

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet Name

Species

If other species, please specify

Breed

(If known)

Colour

Date of Birth or Age

(If known)

Sex

Special Identification

(Microchip, Tattoo, etc)

Pet Insurance?

Please provide company and insurance policy number if you know it

Previous Veterinary Practice

If your pet has been to another clinic, we will contact them on your behalf for a copy of medical records.

Vaccination history

When were last vaccines given, and what kind of vaccines? Please email us any copies of vaccines you may have.

Does your pet have any allergies or drug reactions?

Reactions to vaccinations, medications or anesthesia? If yes, please describe below

Is your pet on any medications?

If yes, please list below

Are there any current or past medical conditions of which we should be aware?

If yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the area below to give us any other relevant information about your pet*

*If you have a small mammal/bird/reptile, please list housing set up, dietary habits, if there is more than one animal in the habitat, etc.

Photo Permission

Do you agree to use of your pet's photo on our website, social media accounts, and/or promotional/educational materials, either digital or in print, in perpetuity?

Get In Touch With Us!

Email

Address

Phone

Fax