Client / Patient Registration Form

Client / Patient Registration Form

Please fill out this form and provide it to us by:
(1.) clicking the "Submit Form" button to email it to us, or
(2.) printing it and bring the form to your appointment, or
(3.) faxing the form to 403-246-5725.

Name of owner: *

First Name Last Name

Name of additional owner (if applicable):

First Name Last Name

Address *

Street Address
Street Address Line 2
City	Province
Postal Code	Country

* NOTE: An e-mail address is required in order to send out medical and vaccination reminders for your pet. *

E-mail *

Select your preferred primary contact phone number:

Home Cell Work

HOME Phone Number

Area Code Home Phone Number

CELL Phone Number

Area Code Cell Phone Number

WORK Phone Number

Area Code Work Phone Number

How did you hear about the Glamorgan Animal Clinic?

I have been a client here before Location Website Phone book Advertisement Another veterinary clinic

Pet's name: *

Gender: *

Female Male

Spayed or neutered? *

No Yes

Birth Date: *

Month Day Year Date Picker Icon

Species: *

Dog Cat

Breed:

Colour/Markings:

Microchip:

No

Tattoo:

No

Is your pet insured?

No

List any previous medical conditions or adverse reactions to medications or vaccinations:

List any medications, supplements, and/or prescription diets:

I grant to Glamorgan Animal Clinic representatives and employees the right to take photographs of my animal(s) for their medical records and to document any health issues.

I grant to Glamorgan Animal Clinic authorization to transfer my medical record and personal information when required to another veterinary clinic for, but not limited to, referrals, emergencies, boarding, grooming, etc.

I grant to Glamorgan Animal Clinic authorization to send electronic and mail post communications, such as reminders, alerts, messages, newsletters, etc. I am aware that I can unsubscribe at anytime by following the prompts on the electronic messages or by contacting the clinic directly.

Please select one of the following: *

I agree to the policies above. I do not agree to the policies above.

CLIENT INFORMATION

ANIMAL INFORMATION