New Client Registration Form

Which practice would you like to register with?

Location

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Owner Information

Full Name*

Phone Number*

Full Name of Spouse/Other

Phone Number of Spouse/Other

Address*

City*

Province*

Postal Code

Email Address*

Emergency Contact Name and Number

If Personal Referral, is there someone we can thank for this referral?

Pet Information

Pet's Name*

Species*

Breed (if known)

Colour

Date of Birth or Age (if known)

Sex

Previous Veterinary Practice (if any)

Please use the following box to give us any other relevant information about your pet

Privacy Consent

At Baker Animal Clinic we respect your right to privacy. The information we seek from you is obtained so that we can provide a high quality of veterinary service and ensure that you are fully aware of your action with regards to your pets. We will not collect or disclose any personal information regarding you or your pet for the purpose of external marketing by the clinic or outside companies. We are required by the Veterinarian Act, and by law, to release pertinent information concerning your pet to the Department of Health, if requested. Having read the above paragraph, I give my permission allowing Baker Animal Clinic to keep and maintain our/my information.

Electronic Signature (name and initials)*

Security Question

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY **

New Client Registration Form

Which practice would you like to register with?

Owner Information

Pet Information

Privacy Consent

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