JBV - New Client Form

Appointment Information

James Bay Veterinary Clinic
Do you already have an appointment booked with us? *

Yes No
If no, what day and time would like to request?

Month Day Year
at
Hour Minutes AM/PM Option Date Picker Icon
Please note that your appointment is not booked until it has been confirmed by

At Home Vet Care
Owners Information
Full Name *

First Name Last Name
Primary Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Spouse's Information
Spouse's Name

First Name Last Name
Spouse's Phone Number

Area Code Phone Number
Spouse's E-mail
May we send you reminders, notices, and information by email?
Pet Information
Please fill out all of the following information about your pet.
Pets Name *
Species *
Breed *
Color *
Birth Date *

Month Day Year
Sex *

Female Male
Fixed *

Yes No Unsure
Last Vaccinations
Previous Clinic
Medical Issues
Pet Insurance *

Yes No
If yes, which company
Policy #
Microchip/Tattoo #
Have your pets traveled outside of the area? *

Yes No
If yes, where have they traveled?
Do you have any other pets?
Should be Empty: