REGISTRATION

Registration

#202 – 20434 64 Avenue, Langley, BC Phone: 604-514-8383 | FAX: 604-427-2494 www.bbvsh.com | info@bbvsh.com | This form can be found again at bbvsh.com/registration
Contact Information
During the COVID-19 outbreak, the health and safety of our clients, patients, employees, doctors and our community is paramount. As such, we are required by the College of Veterinarians of British Columbia to take additional precautions in providing care to patients from at-risk or COVID-positive households.
Are you, someone in your household, or someone with close contact with your pet either COVID-positive or experiencing any symptoms of COVID-19 (including sore throat, cough, fever, or difficulty breathing)? *

Yes No
Which best describes your visit today: *

I'm here for an emergency: My family vet did not tell me to come I'm here for an emergency: My family vet submitted a referral on my behalf (aka "direct transfer") I'm here for a specialty or other scheduled appointment
Are you ... *

the owner an agent
Your Name *

First Name Last 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 No
Would you like to receive relevant updates via email?

Yes
Patient Questionaire
Patient Name *
Breed *
Colour
Species *
Sex *

Female Male Female Spayed Male Neutered
Birthdate OR Age *
e.g. 01/31/2009 or 9 years
Family Veterinarian *
Name of clinic
Fax/email records to family vet? *

Yes No
Insured? *

Yes No
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
Feedback on this form? Send your thoughts to marketing@bbvsh.com
Newsletter

Yes, subscribe me to this newsletter.
Should be Empty:

Contact Information

Patient Questionaire