Client Registration Form and Privacy Policy

Owner's Name

Name*

First Last

Primary owner. This is the person most likely to bring the pet into the clinic, and also the main contact.

Address

Address*

Street Address Address Line 2 City Province Postal Code

Preferred Phone*

Please tell us which number to call you at first

What type of number is this?*

Secondary Phone

Please tell us which number to call you at if we can't reach you at your preferred number

What type of number is this?*

Co-owner's Name & Contact #

Name

First Last

Cell Phone

Work Phone

Receiving Reminders and Newsletters*

Do you consent to receiving emailed vaccination and/or medication reminders, and a clinic newsletter (once every few months)?

If you choose NOT to receive emailed reminders, you will receive a postcard in the mail instead.

Yes
No

Email*

Enter Email Confirm Email

How did you find out about our practice?

If Other, please specify:

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

Pet Information

Pet's Name*

Species*

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification

Tattoo or microchip number

Sex

Photos of your pet*

We love your pet, and from time to time we may take photos and post them on our Facebook and Instagram pages. We will not include any owner information. Is it OK to take photos of your pet and post them on social media?

Yes
No

Privacy Policy

Please read our privacy policy below.*

Situations where the collected information may be used internally by staff of Millwoods East Veterinary Clinic Ltd:
1. To contact you regarding the results of tests, further treatment recommendations, or the progress of recovery.
2. To remind you either by telephone, mail or email that vaccination boosters or other preventative treatments, laboratory tests or medications are due.
3. For billing purposes.

Situations where the collected information may be used externally and disclosed to a third party:
1. To a pet insurance company, when the company requests a medical file for a claim.
2. To provide your name, address, and telephone number to the Edmonton Animal Care and Control or the Edmonton Humane Society if they have recovered your lost pet, or to provide your phone number to an individual that has found your pet and we have traced your information through a Rabies tag from our clinic.
3. If your pet is injured when you are not present and it is taken to another veterinary clinic for emergency care.
4. If blood results, and/or radiographs are requested by a referred veterinary clinic for diagnostic testing, treatment, or surgery.
5. If you have requested your file and pet’s medical records sent to another clinic.
6. Microchip or Tattoo registration.

I agree to the privacy policy and allow Millwoods East Veterinary Clinic to use my information ONLY in the situations outlined above:

Owner's Name

Address

Co-owner's Name & Contact #

Pet Information

Privacy Policy

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