New Client Registration Form Please take a moment to complete and send this owner and pet registration prior to your first visit. We look forward to meeting you! Date and time of currently scheduled appointment (dd/mm/yyyy). * Reason for appointment. Primary Owner Name * First Name Last Name Co-owner Name First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Confirm email Cell Phone Number * (###) ### #### Home Phone Number (###) ### #### Other Phone Number (###) ### #### Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### How did you find out about our clinic? Clinic Location Personal Referral Internet Search/ Website Clinic Sign Newspaper/ Print Media Other If other, please specify: If personal referral, is there someone we can thank for their referral? Please use this area to give us any other relevant information about yourself and/or your family Pet Name * Species * Dog Cat Gender Male Female Neutered Male Spayed Female Birthdate (can be estimated if unknown) MM DD YYYY Breed (if known) Colour Microchip and/or Tattoo Number Approximate weight What does your pet eat? Include food and treats. Does your pet have any known allergies or drug reactions? If yes, please list them here. Name of vaccines and date last administered, if known (dd/mm/yyyy). Is your pet on any medications or supplements? If yes, please list them here. What else would you like us to know about your pet ? Please provide the name of your previous veterinary clinic (if any). Please provide contact information for your previous clinic (phone number and/or email). Does this pet have veterinary insurance? Yes No Insurance Provider and Policy # if known: If you have additional pets, please list their information here (including name, species, breed, colour, age, and gender): Payment Policy Payment is due when services are rendered. We accept the following methods of payment: debit, Visa, MasterCard, cash and cheque. Privacy Policy In accordance with the Privacy Act, I understand my rights for privacy and that personal information will not be released without my consent. I consent and authorize Beaverdale Veterinary Clinic to disclose the necessary personal information required for the continued good health of my pet, in communicating with other veterinarians, specialists and any other relevant third party. I have read and understand the payment policy and consent to the privacy policy. * Yes No Date * MM DD YYYY Thank you!
