New Client Pet Parent Information * First Name Last Name Email * Mobile Phone * (###) ### #### Home Phone (###) ### #### Work Phone (###) ### #### Preferred Contact Method Phone Text Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country If applicable, provide an alternate contact authorized to make medical and financial decisions for your pet(s): First Name Last Name Phone (###) ### #### Pet's Name * Species * Dog Cat Date of Birth * MM DD YYYY Sex * Male Female Neuter Male Spayed Female Breed Colour Does your pet have a microchip? Yes No Microchip Number Does your pet have Pet Health Insurance? Insurance Policy Number Say Cheese! Can we take your pet's photo? Yes No Photos are added to your pet’s medical record and may be used in social media. If we were to take a picture of your pet, we would like your permission to use it in our social media content, promotional materials and/or publicity efforts. These photo may be used in publications, print ads, direct-mail pieces, electronic media (e.g. video, website) or other forms of promotion in perpetuity without remuneration or further consent. Your pet’s name may be shared, but your identifying information would not be. Your Pet’s Social Account How Did You Hear About Us? * Signage Mail Advertisement Internet Search Social Media Referral Other Authorization * The information provided is accurate to the best of my knowledge. I hereby authorize My Animal Veterinary Clinic to provide veterinary care for my pet(s) from this date forward. I understand that I am responsible for all charges incurred for the care of my pet(s) and that payment is due at the time services are rendered. Check box to certify by electronic signature Authorized Electronic Signature * Date * MM DD YYYY Welcome to the family! We look forward to meeting you soon.
