REGISTRATION

Contact Information

Which best describes your visit today:*

I'm here for an emergencyI'm here for a specialty or other scheduled appointment

Are you ...*

the owneran agent

Your Name*

First NameLast Name

Secondary Contact Name

If relevant, list other caregiver, spouse, partner, relative, etc.

Street Address*

City*

State / Province*

Postal Code*

Primary Phone*

(XXX) XXX-XXXX

Secondary Phone

(XXX) XXX-XXXX

Email Address*

example@email.com

A note about email: Staff will communicate with you via email with information pertinent to your pet's treatment. Additionally, if you give your permission, we'll also add you to our email list where you'll get important, occasional updates that are relevant to pet owners (for example, "We're now open 24/7 for emergencies"). You can unsubscribe at any time.

Would you like to receive relevant updates via email?

Yes

Patient Name*

Breed*

Colour

Species*

Sex*

FemaleMaleFemale SpayedMale Neutered

Birthdate OR Age*

e.g. 01/31/2009 or 9 years

Family Veterinarian*

Name of clinic

Fax/email records to family vet?*

YesNo

Insured?*

YesNo

Which insurance company?

Present complaint*

describe the reason for your visit

OPTIONAL: How did you find us? We'd love to learn the specifics of how you discovered us for your pet's treatment:

e.g. My vet Dr. Verne at Crossroads Clinic, I searched Google for Vancouver emergency hospital , I saw your ad on Facebook, etc

E-signature Agreement

Where a signature is requested or required, you agree that an “E-Signature,” signed in counterpart (if applicable), is valid, enforceable, and deemed to be your original signature delivered to Boundary Bay Veterinary Specialty Hospital in writing. “E-Signature” means any information in electronic form that you create or adopt to sign, attach to, or associate with a record, including the act of typing your name or any other electronic information in any form which confirms your acceptance, approval, consent, and/or authorization documented in any record (e.g. forms, agreements, contracts, authorizations of payments, or any other documents). You agree that the use of your E-Signature in any record will have the same legal validity and enforceability as a manually executed signature to the fullest extent permitted by law, without any necessity for certification of the E-Signature (by a third party verification or otherwise). In all circumstances, Boundary Bay Veterinary Specialty Hospital will be entitled to rely on your E-Signatures with regard to any record, as if it was an original signature delivered in writing.

Client Signature Required

Clear

Media Release

Boundary Bay Veterinary Specialty Hospital's doctors and staff believe that "moments matter" and we love to be able to share wonderful moments with pet photos, videos and interesting stories on our social media pages (i.e.: Facebook, Instagram and YouTube), website and TV slideshow/videos. However, we cannot do it alone! Will you help us by granting permission to use photos/videos of your pet(s) and his or her story and granting us permission to interview you and use pictures/videos of you (you may choose one or the other or both)?

I hereby grant Boundary Bay Veterinary Specialty Hospital permission to use the likeness, pet name (not client last name) and/or story of my animal as named above in photograph(s)/video/written publications in any and all of its publications and in any and all other media, whether now known or hereafter existing, in perpetuity. I will make no monetary or other claim against Boundary Bay Veterinary Specialty Hospital for the use of the interview and/or the photograph(s)/video. I understand that, while I waive the right to inspect any photos or videos prior to their use, any media images taken of my pet will be used for educational, advertising and entertainment purposes and will show my pet(s) in a favorable light. I also understand that, I have the right to request copies of all photos or videos taken of my pet(s).

Do you consent to media images of your pet??*

YesNo

Client Initials*

Clear

I hereby grant Boundary Bay Veterinary Specialty Hospital permission to interview me, use my first name, and to use my likeness in photograph(s)/video/written publications in any and all of its publications and in any and all other media, whether now known or hereafter existing, in perpetuity. I will make no monetary or other claim against Boundary Bay Veterinary Specialty Hospital for the use of the interview and/or the photograph(s)/video. I understand that, while I waive the right to inspect any photos or videos prior to their use, any media images taken of my pet will be used for educational, advertising and entertainment purposes and will show my pet(s) in a favorable light. I also understand that, I have the right to request copies of all photos or videos taken of me.

Do you consent to media images of yourself?*

YesNo

Client Initials*

Clear

Client/Veterinary Hospital Code of Conduct

Boundary Bay Veterinary Specialty Hospital values your business and are honoured you’ve entrusted us with your pet’s care. At the heart of a good veterinary, client, patient relationship is trust and mutual respect. We will treat you with compassion and respect when you come through our doors and ask the same of you. Abusive language, aggressive behaviour, and lack of respect any of our staff members will not be tolerated.

Emergency Service wait times may be long due to COVID and a province-wide veterinary labour shortage. We operate the Emergency Service on a triage basis; the most critically ill patients are seen first. Your pet will be triaged to assess how critically ill he/she is and the most critically ill patients will be seen first. If you are experiencing a long wait time, be thankful that your pet is stable enough to wait.

Diagnostic work-ups and treatment plans are services we provide with the goal of reaching a diagnosis and having a favorable outcome for you and your pet. Unfortunately, not all diagnostics uncover an answer and not all outcomes are favorable; this is due to the nature of disease. While these services are performed with the intent to provide a diagnosis and help your pet through their illness or emergency it is important you understand it is the services provided you are paying for, not the outcome.

Please initial your acknowledgement and agreement with this code of conduct so we can proceed with providing care for your pet.

I will treat each and every staff member at BBVSH with respect.

Client Initials*

Clear

I accept that if my behaviour is deemed disrespectful or aggressive, the care of my pet may be transferred elsewhere.

Client Initials*

Clear

I acknowledge that there may be an extended wait time and understand that my pet is being seen as quickly as is possible. If I am made to wait, I understand that this means the veterinary staff are dealing with a more critically ill pet than my own.

Client Initials*

Clear

I understand that when I am presented with an estimate and the final bill for my pets’ care I am paying for medical services rendered. I am not paying for an outcome.

Client Initials*

Clear

Feedback on this form? Send your thoughts to marketing@bbvsh.com

Contact Information

Patient Questionaire

Legal Acknowledgements

E-signature Agreement

Media Release

Client/Veterinary Hospital Code of Conduct