New Client Registration Form Owner's Name First Name (required) Last Name (required) Co-Owner's Name First Name Last Name Address Address (required) Street Address (required) Address Line 2 City (required) Postal Code (required) Province Eastern CapeWestern CapeNorthern CapeNorth WestFree StateKwazulu NatalGautengLimpopoMpumalanga Day-Time Phone (required) Evening Phone Mobile Phone Your Email (required) Preferred Contact Method (required) How did you find out about our practice? Clinic Location (Drive-By)Personal ReferralInternet Search / WebsiteClinic SignOther If Other, please specify: If Personal Referral, is there someone we can thank for this referral? Preferred Contact Method (required) Call home phoneCall mobile phoneText mobile phoneEmail Please use this area to give us any other relevant information about yourself or your family Pet Information Pet's Name (required) Species CatDogExotic Breed (if known) Colour Date of Birth or Age (if known) Sex Neutered MaleSpayed FemaleMaleFemaleUnknown Special Identification (tattoo, microchip, etc.) Previous Veterinary Practice (if any) What is the duration of the last rabies vaccine (could be anywhere from 1 to 3 years)? Can you provide a valid rabies certificate?* YesNo Is your pet on any medications or supplements? YesNo If Yes, please list the medications or supplements What food does your pet eat? Does your pet have any known allergies or past drug reactions? YesNo If Yes, please list the allergies and/or reactions Are there any current or past medical conditions of which we should be aware? YesNo If Yes, please comment on the condition(s) and indicate if they are current or past conditions Please use the following box to give us any other relevant information about your pet Appointment Have you already scheduled an appointment with us at Ikhala Veterinary Clinic? YesNo If Yes, please enter the date and time of your scheduled appointment below. Do you have a copy of your pet's medical records available to bring to the clinic? YesNoWaiting for previous veterinarian to send records already requested Electronic Signature* (required) By entering your full name below, you are acknowledging that you understand that payment is required when services are rendered. For your convenience, we accept cash, checks, MasterCard, Visa, Discover, or Care Credit. By entering your full name below, you assume responsibility for all charges incurred in the care of this animal, and you verify that all information provided is accurate. In the event that your account becomes delinquent and is sent to a collection agency, you agree to pay all incurred fees including collection costs, attorney fees, and court costs.