Client Info Form - AES Underwood - After Hours Vet Australia

Client Information Form - Underwood

Information About You

If the situation is urgent just fill in the required fields and press submit.

Have you had a pet treated within this building before?(Required)

Name(Required)

Title First Name Last Name

Mobile Phone Number(Required)

Alternative Contact Name(Required)

First Last

Relationship to you (Partner, Mother, Friend etc)

Alternative Contact Mobile Phone Number(Required)

Your Email Address(Required)

Your Address(Required)

Street Address City Post Code

How did you hear about Animal Emergency Service?(Required)

Other(Required)

Please tell us how you heard about us.

Why did you choose Animal Emergency Service when you needed an emergency vet today?(Required)

Other(Required)

Tell us more about why you chose to visit us today.

Help us get to know your pet

Patient Name(Required)

Patient Species(Required)

Other(Required)

Please tell us what species your pet is.

Patient Breed(Required)

Colour

Sex of patient(Required)

Is your pet desexed?(Required)

Date of birth/approximate age(Required)

Weight in KG

Are we seeing another pet today?(Required)

2nd Pet's Name(Required)

2nd Pet's Species(Required)

2nd Pet's Breed(Required)

2nd Pet's Colour

2nd Patient's Weight in KG

2nd Pet's Sex(Required)

Is your 2nd pet desexed?(Required)

2nd Pet's Date of birth/approximate age(Required)

Do you have pet insurance?

No matter how gentle your pet normally is, he or she may find a trip to the vet stressful. Tick this box if your dog may require a muzzle, for our safety and yours.

Yes my pet needs a muzzle

For our safety and yours, please let us know if your pet has previously bitten a human(Required)

For our safety and yours, please let us know if your pet has been registered as a dangerous animal with any government council within Australia(Required)

Please let us know which veterinary clinic looks after your pet during normal hours(Required)

Other(Required)

This information is important to us as we work closely with your vet clinic so they can provide a continuation of medical care for your pet after you leave us.

Your visit today

What is the main reason you have attended the clinic with your pet?(Required)

Any medications your pet is taking

Any pre-existing medical conditions we should be aware of?

Acceptance of payment terms

I understand that this after-hours clinic charges a $195.00 consultation fee (public holiday consultation fee $234.00) plus treatment costs and that full payment is required following the consultation.

I will pay my account by(Required)

Please tick this box if you do not wish to have photos and videos taken of your pet during their stay for us to share on our social media channels. We will not share any identifying details about you and will remove collars and tags so your pet is only identifiable by name.

Do not take photos/videos of my pet

AES is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say you would like us to contact you:

I consent to receive marketing emails

You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

By clicking submit below, you consent to allow AES to store and process the personal information submitted above to provide you with the service requested.