New Client Registration Form – Veterinarians Calgary Alberta

Owner's Name

Name*

First Last

Co-owner's Name (if applicable)

Name

First Last

Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone (Owner)*

Mobile Phone (Co-Owner if applicable)

Alternate Phone

Email*

Enter Email Confirm Email

Pet Information

Pet's Name*

Species*

Breed (if known)*

Purebred
Cross

Color*

Date of Birth (preferred) or Estimated Age*

Special Identification (tattoo, microchip, etc.)

Sex*

Do you have more than one pet you wish to register?

Yes
No

Pet Information 2

Pet's Name

Species

Breed (if known)

Purebred
Cross

Color

Date of Birth (preferred) or Estimated Age

Special Identification (tattoo, microchip, etc.)

Sex

Pet Information 3

Pet's Name

Species

Breed (if known)

Purebred
Cross

Color

Date of Birth (preferred) or Estimated Age

Special Identification (tattoo, microchip, etc.)

Sex

Preferred Method of Contact

Email
Phone
Mobile
Text

How did you hear about us?

Who can we thank?

Do you currently have an upcoming appointment?*

Yes
No

If yes, when?

Personal Information Consent

At Midlake Veterinary Clinic we respect your right to privacy. Keeping our client's personal information private has always been important to us. We are committed to collecting, using and disclosing information responsibly and only as necessary for the purposes identified to you. The personal information we seek regarding you and your pet(s) is obtained so that we can provide a high quality of veterinary service. In all cases, we will only disclose this personal information in circumstances where we believe it will be beneficial to the continued good health of your pet. Midlake Veterinary Clinic will not give, sell or unnecessarily utilize this information. **Please toggle EACH option ONLY IF YOU CONSENT to permit us to use or disclose information in these typical situations:*

Patient Reminders - annual health exams, blood testing requirements, vaccine titers, etc
Email of timely information within the pet industry - outbreaks, tick season arrival, pet food recalls, etc
Referral of medical records - specialist referrals, alternate therapy referrals, second opinions, transfer of care, insurance claim purposes
Medical records transfer - moving, changing veterinary care
Submission of medical records when requested by a Peace Officer, Bylaw Officer or Court Order (IF optional)
Prescribing medication by phone, fax or email - pharmacy, other veterinary clinic, other

Consent*

I agree to the privacy policy.

E-Signature required - Print full name in box below*