New Client Form

CLIENT INFORMATION

Primary Owner Full Name *

Secondary Owner

Address *

City *

Province *

Postal Code *

Primary Phone Number *

Secondary Phone Number

Email Address *

*By providing your email, you consent to receive email communications from our Clinic (including but not limited to vaccine and appointment reminders, follow-up correspondence, and newsletters)

What is the best way to get in contact with you?

How did you hear about us? Please be specific.

If you were referred to us, let us know who referred you:

AUTHORIZED REPRESENTATIVE

This individual acts to provide consent for your pet’s treatment in situations when you, the owner, cannot be contacted.

Full Name *

Phone Number *

PET INFORMATION

Pet's Name *

Species *

Gender *

Breed *

Colours/Markings *

Birth Date or Age *

Microchip/Tattoo Number

Previous Vet Clinic (if any)

Do we have permission to request your pet's vet records?

Yes
Please contact me first

Any relevant medical history?

Please note we accept cash, Visa, MasterCard, American Express and Debit Card as payment. We cannot accept cheques.

PERSONAL INFORMATION POLICY

I understand that Davisville Park Animal Hospital has a Personal Information Policy in accordance with the requirements of the Personal Information Protection and Electronic Documents Act.

By signing below, I am consenting to the collection, use and disclosure of my personal information (such as my home telephone number and address) in accordance with the purposes set out in the Policy, which include the following:

maintaining complete and accurate client files, and complying with the requirements of the College of Veterinarians of Ontario, the Veterinarians Act and regulations under the Act;
providing goods and services to veterinary clients, including contacting clients to schedule appointments and follow up on patient treatment, billing for goods and services and notifying clients about new services and promotional offers; and
communicating and working with third parties providing veterinary medical or other services to clients, including other veterinary facilities and insurance companies which may pay for all or part of the cost of such services.

I understand that:

my personal information will not be used or disclosed for purposes other than those for which it was collected, except with my consent, or except where use or disclosure is required by law;
I have the right to view my personal information and have it amended, if inaccurate or incomplete; and
a copy of the Policy will be provided on request.

A $50.00 deposit will be required at the time of scheduling to secure your appointment. If the appointment is canceled with less than 48 hours' notice, the deposit will be applied towards our no-show or late cancellation fee.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Print	Yes No
Email	Yes No
SMS/Text	Yes No
Phone Calls	Yes No

Newsletter	Yes No
Use of Pictures/Videos	Yes No