Currimundi Veterinary Surgery

5493 8222

698 Nicklin Way, Currimundi
After Hours : AES 54451333

Register a new pet with us.

Click here to REGISTER and then you can BOOK ONLINE

or fill in this form below ONLY IF YOU ARE NOT ABLE TO REGISTER VIA THE ABOVE LINK and this will email your details to us, then your details will already be in our system when you visit our clinic. It's a handy time saver for you.

Contact Details

First Name:

Surname:

Additional Contact:

Address:

Phone (H)

Mobile:

Work:

Email Address

Pet Details

Pet Name:

Cat/Dog/Other:

Breed:

Colour:

Sex

Male Female

Desexed

Yes No

Microchip ID:

(This could also be your pets Microchip number)

Date of Birth:

Date of Last Vaccination:

Type of Vaccination:

(Please type in what was on your last vaccination record - e.g. 15 June 2012 Protech C3 plus Bronchi-Shield III)

Date of Last Worming:

Heartworm Prevention:

Yes No

(if yes, please specify brand ...)

Is Your Pet Insured?:

Yes No

Insurance Provider

Policy Number:

Check this box to register additional pets.

Additional Pet

Pet Name:

Cat/Dog/Other:

Breed:

Colour:

Sex

Male Female

Desexed

Yes No

Microchip ID:

(This could also be your pets Microchip number)

Date of Birth:

Date of Last Vaccination:

Type of Vaccination:

(Please type in what was on your last vaccination record - e.g. 15 June 2012 Protech C3 plus Bronchi-Shield III)

Date of Last Worming:

Heartworm Prevention:

Yes No

(if yes, please specify brand ...)

Is Your Pet Insured?:

Yes No

Insurance Provider

Policy Number:

How did you find out about our clinic?

Website Yellow Pages Newsletter Passing By/Saw Sign Friend/Existing Client Other (Please Specify below)

(If refered by a friend, please type their name and address so that we can thank them in the above field.)

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This information will be sent to your veterinary clinic so they can update your pet’s file and they may also use it to remind you when vaccinations are due, confirm upcoming appointments, advise you about local health alerts and provide information that relates to your pet’s health or clinic promotional offers. A copy of this information will also be received by the website hosting company for data recovery purposes only, if required.

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