Bendigo Pet Vets - Mobile Veterinary Clinic
Dr. Mandy Lugsdin & the Pet Vets Team
Bendigo, Vic, 3550, AU
03 4415 4200
welcome@bendigopetvets.com.au

Bendigo Pet Vets - Mobile Veterinary Clinic - New Client Form

We're excited to welcome you to our practice. To help get to know you and your pet, we ask that you complete this new client form so that we can best meet your requirements during the visit.

Client Details

Client first name

Client last name

Email address

Phone number

Animal name

Animal species (e.g. dog, cat, horse)

Animal breed

Animal sex (e.g. male, female, unknown)

Animal date of birth or age

Current address

PET DETAILS

Select sex

   Entire male
   Neutered male
   Entire female
   Neutered female

Please provide details of any additional pets you may have (Name, Species, Breed, Age, Health history).

PET MEDICAL HISTORY

Type & date of last vaccination

Name & date of last worming

Name & date of last heartworm prevention.

Please list any pet health concerns.

Please list any of the medications that your pet is currently on.

Previous vet clinic (to obtain history if needed)

Is your pet microchipped?

Yes
No

REASON FOR VISIT

Please select your reason for visit

   General health check
   Vaccination
   Health concern
   Other

Other:

PET HEALTH INSURANCE

Please list any current pet health insurance cover.

HOW DID YOU HEAR ABOUT US?

Please select how you found out about our practice.

   Saw our fabulous clinic van
   Search engine e.g. Google
   Social media e.g. Facebook
   Word of mouth
   Bendigo Pet Vets website
   Local paper
   Other

Other:

FRIEND REFERRAL

Were you personally referred? Please insert the name, mobile number, and email address (if known) of the kind person who referred you and they will receive a $10 credit on their account. Start referring friends to receive the same benefit! (Not redeemable for cash)

REFER A FRIEND PROGRAM

Receive a $10 credit on your account for every friend/colleague you successfully refer to us (not redeemable for cash)

OTHER COMMENTS

Please make any other comments here.

TERMS & CONDITIONS

I am the owner of the above described Pet or have authorisation from the owner to consent to treatment.
I accept financial responsibility of the veterinary services my Pet receives.
I understand and accept that payment is due at the time of service.
I understand that Bendigo Pet Vets do not do personal accounts and if there are money concerns these will be raised with a staff member prior to accepting treatment.
I understand that I can seek financial assistance through specific veterinary loan companies such as OpenPay and Vetpay.

Signature

Clear

Title

Full name

Date of signature