Microchip Registration- GAH

Greenbank Animal Hospital

Nepean Rideau Veterinary Professional Corporation

3160 Greenbank Rd

Ottawa, On K2J 4H6

613-825-2902

Client Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Alternative Contact Person

First NameLast Name

Alternative Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Pet's Name*

Pet's Date of Birth

Species*

Breed

Pet Colour

MaleMale/NeuteredFemaleFemale/Spayed

YesNo (you prefer that communication only be through 24 Pet Watch)

With your 24Pet® microchip, Pethealth Services Inc. may offer you free lost pet services, as well as exclusive offers, promotions and the latest information from 24Pet regarding microchip services. Additionally, PTZ Insurance Services Ltd. may offer you promotions and the latest information from Pets Plus Us® regarding pet insurance services and products. By checking “Yes”, Pethealth Services Inc. and PTZ Insurance Services Ltd. may contact you via commercial electronic messages, automatic telephone dialing systems, pre-recorded/automated messages or text messages at the telephone number provided above, including your mobile number. These calls or emails are not a condition of the purchase of any goods or services. You understand that if you choose not to provide your consent, you will not receive the above-mentioned communications or free lost pet services, which includes being contacted with information in the event that your pet goes missing.*

YesNo (you will NOT be contacted in the event that your pet goes missing; you may receive electronic enrollment notification regarding the trial/gift/voucher of insurance and/or free lost pet services which you can choose to unsubscribe)

YesNo

Please verify that you are human*