Examination Intake

Date of the appointment*
Date Format: MM slash DD slash YYYY

Please let us know the date the appointment is booked for, not the date you fill in this form.
Primary Owner(s) Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Email*
Phone (The one we will call you on)*
This is the phone number we will use to call you once the veterinarian has examined your pet so please make sure you have your phone on you and please stay close to the clinic.
Secondary Contact Name
First Last
Secondary Contact Phone Number
Pet's Information
Pet Name:*
Pet date of birth*
Date Format: MM slash DD slash YYYY
Species*
Breed*
Colour*
Upload a picture (optional)
acceptable formats: jpg, gif, png, pdf
Presenting Complaint: What is your pet here for today?*
Duration of time (When did the problem start, has it changed, better, worse, same?):*
Diet (EXACT brand, amount, frequency):*
Any Vomiting/Diarrhea/Coughing/Sneezing?:*
Is the pet currently on any MEDICATIONS INCLUDING SUPPLEMENTS (Name, amount, frequency, last given):*
Any other pets in the house? Are they affected?*
Any changes in appetite or drinking/urinations (drinking or peeing more often?):*
Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc. If not, would you like to pick some up today?*
Indoors/Outdoors?*
Are your pet's vaccines up to date?*
Any other information you would like the doctor to know before your pet's exam today?*
Consent*
I agree to the privacy policy.
Privacy Policy: I understand that Centre Street Animal Hospital has a personal information policy in accordance with the requirements of the Personal Information Protection and Electronic Documents Act.

I am consenting to the collection, use and disclosure of my personal information (such as my home phone number, email address and street address) in accordance with the purposes set out in the Policy, which include the following:

1. Maintaining complete and accurate client files, and complying with the requirements of the College of Veterinarians of Ontario, the Veterinarians Act and regulations under the Act;

2. Providing goods and services to veterinary clients, including contacting clients to schedule appointments and follow up on patient treatment, billing for goods and services and notifying clients about new services and promotional offers;

3. Communicating and working with third parties providing veterinary medical or other services to clients, including other veterinary facilities and insurance companies which may pay for all or part of the cost of such services.

I understand that:

1. My personal information will not be used or disclosed for purposes other then those for which it was collected, except with my consent, or except where use or disclosure is required by law;

2. I have the right to view my personal information and have it amended, if inaccurate or incomplete;

3. A copy of the Policy will be provided on request.
Do you grant us permission to display images and videos of your pet(s) on our public social media accounts (Facebook, Instagram, Youtube, Twitter, etc)?*
- Yes
- No
COVID-19 Screening*
- I do not have any symptoms of COVID-19 and I have not been in contact with anyone who has tested positive within the last 14 days.
Signature*

Pet's Information

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