TICK QUESTIONAIRE Please complete and sign. ANIMAL PATIENT REGISTRATION FORMWhich Clinic are you visiting?(Required) Pymble Killara Owners Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Email PhoneResidential Address Street Address City Post Code Is Mailing Address different from above? Yes Mailing Address Street Address City ZIP / Postal Code Who referred you?Pet DetailsPATIENT Animal Dog Cat Bird Other Pets BreedPets Date of Birth DD slash MM slash YYYY Pets NamePets ColourSex Male Female De-sexed Yes No Microchip NumberWeight (kg)Last Vaccination DateFlea, Tick, and Worming Program(s)Pet Insurance CompanyInsurance Policy NumberDo you want to register another Animal? Yes Pet Details (2)PATIENT Animal Dog Cat Bird Other Pets BreedPets Date of Birth DD slash MM slash YYYY Pets NamePets ColourSex Male Female De-sexed Yes No Microchip NumberWeight (kg)Last Vaccination DateFlea, Tick, and Worming Program(s)Pet Insurance CompanyInsurance Policy NumberPermission to use any photos we may take on social media Yes No I declare that I am over 18 years of age I am the owner of this pet OR I am authorized by the owner to sign this form (strike out which does not apply) I shall pay by: CASH….. Bankcard…… Mastercard……Visa…..EFTPOS…… I hereby certify that I have read and understood the terms and conditions expressed above and by affixing my signature hereto agree to be bound by same in law. Signature of Owner:Date : 25/03/2025If not owner, agents nameAddress Street Address City ZIP / Postal Code Contact Phone
