Client Information Form - Jindalee - After Hours Vet Australia

Client Information Form - Jindalee

Information About You

If the situation is urgent just fill in the required fields and press submit. Please check-in using the Queensland Government COVID 19 check-in app at your earliest convenience.

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

How many people are in your group?(Required)

For COVID-19 contact tracing purposes, we require you to provide information about how many people are with you.

Name(Required)

Title First Name Last Name

Mobile Phone Number(Required)

Alternative Contact Name(Required)

First Last

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 (please specify)(Required)

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

Other (please specify)(Required)

Help us get to know your pet

Patient Name(Required)

Patient Species(Required)

Other (please specify)(Required)

Patient Breed(Required)

Colour

Weight in KG

Sex of patient(Required)

Is your pet desexed?(Required)

Date of birth/approximate age(Required)

Are we seeing another pet today?(Required)

2nd Pet's Name(Required)

2nd Pet's Species(Required)

2nd Pet's Breed(Required)

2nd Patient's Weight in KG

2nd Pet's Sex(Required)

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 (please specify)(Required)

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 $158.00 consultation fee (public holiday consultation fee $183.90) 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

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