New Client Registration Form

Owner's Name *

Primary Phone Number *

Secondary Phone Number

Owner's Email *

Spouse/Co-Owner Name *

Co-Owner Phone Number

Owner's Mailing Address *

City *

Province *

Postal Code *

*** Owner's listed above cannot be removed without consent from both parties ***

What is your preferred method of communication for medical & appointment reminders? Choose all that apply (Only the primary owner will receive reminders) *

Email
Mail
Text Message

We occasionally share pet photos on social media, featuring only their name and image. Do we have your permission to take and use photos of your pet? *

Yes - Okay to post photos
No - Please do not use my pet's photo

How were you referred to our practice? *

List other individuals who may authorize treatment of your pet(s):

I agree to be held financially responsible for all pets in this file and to pay all fees, including services authorized by the individuals listed above. All fees are due at the time services are rendered. I understand that any medical or surgical procedure carries some risk and that it is not possible to guarantee a successful outcome of any procedure. This agreement will remain in effect indefinitely from this date, unless I notify Britannia Kingsland Veterinary Clinic in writing, requesting to cancel the agreement *

I agree to receiving marketing and promotional materials

Yes
No, thank you

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *