Welcome to Karori Vet Clinic

Fields marked with a *are required.

Title
First Name(s):*
Surname:*
Home Phone:*
Work Phone:
Mobile Phone:
Alternative phone:
Your street:*
Your suburb:*
Your town:
A contact e-mail address:

	Pet 1	Pet 2
Your pets name(s):
Your pets D.O.B(Age):
Type of animal:
Breed:
Colour:
Sex:
Desexed:
Vaccinated:
Vaccinated on (date):

Would you like us to request records from another clinic?

Name of clinic:

Important Notes:

Critically ill patients MUST and WILL take priority over non-critically ill cases.

Every effort will be made to contact you for approval of cost of treatment, however, if you can not be reached the Veterinarian on duty will take the course of action best for your pet.

We operate a "Pay as You Go" system and payment will be expected at the completion of consultation or discharge of your animal. Fees incurred for collection of monies owing will be the responsibility of the above named person. We accept cash, cheque, Visa or Mastercard.

Under the terms of the Privacy Act 1993, the information contained in this form will not be used for any other purpose than that for which it has been collected.

*By ticking this box you agree to these terms and conditions.