New Client Form Pet Owner's InformationFirst and last name(Required)Spouse first and last name (optional)Email(Required) Primary phone type(Required)Select…MobileLandlinePrimary phone(Required)If you provide a mobile number, we will send you a text when we’re on our way to your home. Please consider providing any additional phone numbers that we can use to contact you if necessary, such as a spouse’s phone, a work phone, or a home landline. You can provide up to three additional numbers below.Would you like to add a second phone? Yes No Whose phone is this?Additional phone(Required)Additional phone type(Required)Select…MobileLandlineWould you like to add a third phone? Yes No Whose phone is this?Additional phone(Required)Additional phone type(Required)Select…MobileLandlineWould you like to add a fourth phone? Yes No Whose phone is this?Additional phone(Required)Additional phone type(Required)Select…MobileLandlineHouse AddressAddress(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Would you like to add a separate mailing address? Yes No Mailing AddressAddress(Required) Street Address Address Line 2 City British ColumbiaAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Names of other people in the household (children, housemates, etc.)(Required)Previous vet clinic(Required)Do we have permission to request records from your previous vet clinic? Yes No Have you already booked an appointment time? Yes No Pet InformationPlease provide information about all of the pets in your household that you may want us to see at some point. You can provide information about up to five pets below. If you have more than five, please make the appropriate selection below after providing information about your first five pets. We will reach out by email to collect the necessary information about your additional pets.First pet:Name of pet(Required)Type of pet(Required) Dog Cat Other If other, please explain (optional)Sex of pet(Required) Male Female Breed of pet(Required)Color of pet(Required)Age of pet (optional)Pet's birthday(Required)Is your pet spayed or neutered?(Required) Yes No Does this pet have health insurance?(Required) Yes No If yes, what is the name of the insurance company? (optional)Is there anything else that we should know about this pet? (optional)Would you like to add a second pet? Yes No Second pet:Name of petType of pet(Required) Dog Cat Other If other, please explain (optional)Sex of pet(Required) Male Female Breed of petColor of petAge of pet (optional)Pet's birthday(Required)Is your pet spayed or neutered?(Required) Yes No Does this pet have health insurance?(Required) Yes No If yes, what is the name of the insurance company? (optional)Is there anything else that we should know about this pet? (optional)Would you like to add a third pet? Yes No Third pet:Name of petType of pet(Required) Dog Cat Other If other, please explain (optional)Sex of pet(Required) Male Female Breed of petColor of petAge of pet (optional)Pet's birthday(Required)Is your pet spayed or neutered?(Required) Yes No Does this pet have health insurance?(Required) Yes No If yes, what is the name of the insurance company? (optional)Is there anything else that we should know about this pet? (optional)Would you like to add a fourth pet? Yes No Fourth pet:Name of petType of pet(Required) Dog Cat Other If other, please explain (optional)Sex of pet(Required) Male Female Breed of petColor of petAge of pet (optional)Pet's birthday(Required)Is your pet spayed or neutered?(Required) Yes No Does this pet have health insurance?(Required) Yes No If yes, what is the name of the insurance company? (optional)Is there anything else that we should know about this pet? (optional)Would you like to add a fifth pet? Yes No Fifth pet:Name of petType of pet(Required) Dog Cat Other If other, please explain (optional)Sex of pet(Required) Male Female Breed of petColor of petAge of pet (optional)Pet's birthday(Required)Is your pet spayed or neutered?(Required) Yes No Does this pet have health insurance?(Required) Yes No If yes, what is the name of the insurance company? (optional)Is there anything else that we should know about this pet? (optional)Do you have more pets to add? Yes No Thank you, your response has been noted! We’ll reach out to collect the additional pet information from you shortly. Please proceed with the new client form when you’re ready.Book AppointmentWould you like to book an appointment?(Required) Yes No Desired Appointment Date MM slash DD slash YYYY Desired Appointment TimeIn a few sentences, please describe what has been going on with your pet(s)Other InformationHow did you hear about us? (optional) Friend or family Referral Facebook Instagram Internet search Website Other Who can we thank for the recommendation/referral? (optional)Are you willing to share the name of the website? (optional)For other, are you willing to explain? (optional)Is there anything else you'd like us to know? (optional)Cancellation PolicyIf you find you need to reschedule your appointment, we require notice at least two business days in advance. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time. Additionally, as a mobile service we need to plan our travel to our appointments in a very specific way. Your assistance will help keep our service running as smoothly as possible.If you are unable to provide sufficient notice for cancelling or rescheduling your appointment, you may be subject to a $183 cancellation fee.Cancellation policy(Required) I understand and consent to the cancellation policy. Payment PolicyPlease note that payment is due at the time of your appointment. We are able to accept e-transfer, Visa, Mastercard, Debit, and cash.We understand that costs associated with pet care can be stressful. If you have financial limitations, we ask that you bring those to our attention at the time of booking. We strive to provide our patients with the best possible care, while also respecting each client’s personal budget.Payment policy(Required) I understand and consent to the payment policy. After Hours PolicyEmergencies happen from time to time, and we want to make sure you’re prepared for when they do.For after hours emergencies in the West Kootenays, there is a call-share agreement between the veterinarians of Nelson Animal Hospital, Selkirk Veterinary Hospital, West Kootenay Animal Hospital, Beaver Valley Animal Clinic, Arrow Lake Veterinary Hospital, and Castlegar Veterinary Hospital. Without a brick and mortar building, Maybank Mobile Vet is not set up to take emergencies, and our patients are not included in the West Kootenay Callshare. While individual veterinarians from the callshare may choose to take our patients after hours in an emergency, they are not obligated to do so. If a Maybank Mobile client does not have a relationship with one of the previously mentioned hospitals, there is a chance that, after hours, they could be referred to an emergency hospital in either Kelowna or Spokane.Our patients will be accepted for daytime appointments, 7 days per week, at Nelson Animal Hospital. We provide 24/7 virtual veterinary support through our VetWise triage answering service (778-760-9011). This service provides telemedicine appointments, via phone call or video, with a veterinarian who can prescribe needed medications. If necessary, VetWise will also direct clients to the appropriate veterinary hospital (locally, if the veterinarian on call has agreed to take our patients that night, or to the nearest emergency hospital in Spokane or Kelowna).If you are a client of Maybank Mobile Vet and one of the previously mentioned clinics, you will be guaranteed after hours care. We encourage all of our clients to establish a relationship with one of the brick and mortar practices in the West Kootenay Call-Share Agreement.After Hours Policy(Required) I understand and consent to the after hours policy Thanks! We’re all done. Go ahead and click the “Submit” button below when you’re ready.Please note: We typically reply to all communications within 24 hours during the week. If you haven’t heard from us within that time, please check your junk mail folder.
