New Client

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

 

Name

First Name:

Last Name:

Preferred Title:

Ms.Mrs.Mr.Dr.

Spouse/Partner Name:

Address

Home Address:

Unit #:

City:

Postal Code:

Contact

Home Phone:

Work Phone:

Cell Phone:

Email Address:

How did you hear about our practice?

If Other: Please tell us how. If Present Client: Please give name so we can thank them

Pet Information

Pet's Name:

Type of Pet:

Breed:

Colour:

Sex:

MaleFemale

Neutered/Spayed:

YesNo

Date of Birth (dd/mm/yyyy):

Microchipped:

YesNo

Pet Insurance Company:

Additional Info

Are your pet's vaccinations current?

YesNo

Do you have a copy of your pet's medical records?

YesNo

What's the best time to call you to confirm this appointment?

What can we do for your pet and you during the appointment?

Special requests or existing health conditions?

Please list any additional pets here:

***For your first visit, please bring a fecal (poop) sample from your pet with you for parasite testing.***

Personal Information Policy

I understand that Bathurst Animal Clinic Professional Corporation has a Personal Information Policy in accordance with the requirements of the Personal Information Protection and Electronic Documents Act.

By agreeing 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 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 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.

Check off box to agree:

Yes, I agree