Client Info Form Information About YouIf the situation is urgent just fill in the required fields and press submit.Have you had a pet treated within this building before?(Required)Please selectNoYes - with Perth Vet EmergencyYes - with VetWestName(Required) Please selectDr.MissMr.Mrs.Ms.Prof.Rev. 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 TodayWhat is the main reason you have attended the clinic with your pet?(Required) How did you hear about Perth Vet Emergency?(Required)Please selectRecommended by my VetInternetRecommended by family/friendBeen here beforeLocation (saw the building/sign)Direct referral from my usual vetOtherOther(Required) Please tell us how you heard about us.Why did you choose Perth Vet Emergency when you needed an emergency vet today?(Required)Please selectClosestQuickest travel timeTop of internet searchGoogle review ratingPositive previous visitTV or radioReputationQuality of emergency careRecommended to meKnew we were hereOtherOther(Required) Tell us more about why you chose to visit us today.Help Us Get To Know Your PetYour pet's name(Required) Your pet's species(Required)Please selectBirdCatDogLizardRabbitRatRodentSmall animalSnakeOtherYour pet's breed(Required) Your pet's colour Your pet's gender(Required)Please selectFemaleMaleYour pet's weight in KG Is your pet desexed?(Required)Please selectYesNoYour 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)Please selectYesNoSecond pet's name(Required) Second pet's species(Required)Please selectBirdCatDogLizardRabbitRatRodentSmall animalSnakeOtherSecond pet's breed(Required) Second pet's colour Second pet's gender(Required)Please selectFemaleMaleSecond pet's weight in KG Is your second pet desexed?(Required)Please selectYesNoSecond 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)Please selectYesNoFor 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 selectYesNoDo you have pet insurance?Please selectYesNoPlease let us know which veterinary clinic looks after your pet during normal hours(Required)Please selectApplecross Veterinary HospitalAscot Veterinary HospitalBasendean Vet HospitalBedford-Dianella Veterinary CentreDoubleview Veterinary HospitalDrovers Vet HospitalGreencross Vets BedfordGreencross Vets JoondalupKingsley Veterinary HospitalKingsway Veterinary CentreMaylands VetMirrabooka Veterinary HospitalMorley Vet Centre And Cat ClinicMt Lawley Inglewood Veterinary HospitalMy Best Friend Veterinary CentreNorth Perth Veterinary ClinicPerth Cat HospitalPETstock Vet MidlandSt Francis Veterinary HospitalSwan Veterinary HospitalVetwest BallajuraVetwest CarineVetwest ClarksonVetwest EllenbrookVetwest WannerooVetwest WhitfordsVetwest YokineVital Vet Animal HospitalOTHEROther(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 TermsI 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)Please selectCashEftposCredit cardI would like information about finance options that are available (VetPay/Zip)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.CAPTCHA