Client Info Form

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 Name Last Name

Alternative Contact Mobile Phone Number(Required)

Your Email Address(Required)

Your Address(Required)

Street Address Suburb Post code

Your Visit Today

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

How did you hear about Perth Vet Emergency?(Required)

Other(Required)

Please tell us how you heard about us.

Why did you choose Perth Vet Emergency 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

Your pet's name(Required)

Your pet's species(Required)

Your pet's breed(Required)

Your pet's colour

Your pet's gender(Required)

Your pet's weight in KG

Is your pet desexed?(Required)

Your pet's date of birth/approximate age(Required)

Is there any medications your pet is taking?

Does your pet have any pre-existing medical conditions we should be aware of?

Are we seeing another pet today?(Required)

Second pet's name(Required)

Second pet's species(Required)

Second pet's breed(Required)

Second pet's colour

Second pet's gender(Required)

Second pet's weight in KG

Is your second pet desexed?(Required)

Second pet's date of birth/approximate age(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)

Do you have pet insurance?

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.

Acceptance Of Payment Terms

I understand that this after-hours clinic charges a $205.00 consultation fee (public holiday consultation fee $245.35) plus treatment costs and that full payment is required following the consultation.

I will pay my account by(Required)

Perth Vet Emergency supports the teaching and development of veterinary students. Please tick this box if you do not want students to be involved in the treatment of your pet.

I don't want veterinary students involved with my pet's treatment

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/video of my pet

Perth Vet Emergency 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 Perth Vet Emergency to store and process the personal information submitted above to provide you with the service requested.

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