New Client and Patient Registration Form

Brookfield new client for web

New Client Registration

Welcome and thank you for giving us the opportunity to care for your pet. Please help us learn more about you and your pet's needs by filling in the information below. When you are finished, click the submit button and the form will automatically be sent to our client service and medical team. Use one form per pet, please.
  • Do you have a spouse or other family member you would like us to add to the account who can make decisions about your pet's healthcare? Please use the field below to list any other pet owners and how they are related to you. All pet owners listed must be 18 years of age or older.
  • In the event of an emergency, it's important that we're able to get in touch with you as soon as possible. Please list any additional number you would like us to have on file and who we should ask for when we call.
  • List any additional email address you would like to provide
  • If you selected a 'friend' or 'other', use the field below to give us more information.
  • Please list your pet's age or birthday. Approximations are okay, but during your visit, let us know if you have guessed your pet's age.
  • Use the field below to list any medications that your pet is currently taking. Please list the name of the drug, the dosage, and how often you give it.
  • Does your pet have any medical conditions or history that we should know about? Please use the field below to list any major medical problems that your pet may have had in the past, any chronic health issues, or anything else that you think will be helpful for us to know when diagnosing or treating your pet.
  • Please use the field below to list the name and contact information (if you have it) of the last veterinarian that treated your pet. Can you also please tell us why you left their care?
  • Use the space below to tell us about any other pets you have at home. List the pet's name, what kind of an animal it is, and how old they are. Information on other pets in the household helps us better diagnose medical issues in our patients.
  • By typing or signing my name below, I acknowledge that I am at least 18 years of age and have the authority to authorize, and currently authorize the veterinarian to examine, prescribe for, and/or treat the above described primary pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospitalization.
  • By typing or signing my name below, I acknowledge that I am at least 18 years of age and have the authority to authorize, and currently authorize Brookfield Animal Hospital to photograph my pet for use on social media. Brookfield Animal Hospital social media posts are used to celebrate the human animal bond and to promote excellent veterinary care for companion animals.
  • Brookfield only accepts the following forms of payment. Please select the payment type you prefer to provide.