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

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