McKnight - Client Registration Form

Client Registration Form
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). Click on each header to expand the section.

PET INFORMATION
Pet's Name (first and last name):*
Species:*
Breed (if known):
Age or Date of Birth:

MonthDayYear
Date
Colour*
Sex*

MaleMale, NeuteredFemaleFemale, Spayed
Special identification (tattoo, microchip, etc.):
Has your pet been vaccinated?

YesNo
Date of last vaccines (if known):

MonthDayYear
Date
Date last seen by a Veterinarian (if applicable):

MonthDayYear
Date
If you currently have a Veterinarian, please enter the name of the clinic:
Pet Insurance Provider (if applicable):

PRIMARY CONTACT
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince/State

Postal/Zip CodeCountry
Primary Phone Number*
Please enter a valid phone number.
Alternate Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about our hospital?*

My VeterinarianInternetWalk-InTrade ShowRescue OrganizationFriendOther
Friend's Name:*

SECONDARY CONTACT
Name

First NameLast Name
Primary Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.

PLEASE NOTE: WE ACCEPT MEDICAL DIRECTIVES FROM SECONDARY CONTACTS THAT HAVE BEEN ENTERED INTO OUR SYSTEM. INFORMATION REGARDING YOUR PETS CAN ONLY BE RELEASED TO INDIVIDUALS AS OWNERS ON FILE. PLEASE ADVISE OUR RECEPTION IF YOU WOULD LIKE TO ADD ADDITIONAL NAMES.

CONSENT FOR EMAIL COMMUNICATION
I agree to allow McKnight Veterinary Hospital (MVH) to contact me via email regarding my pet, including but not limited to appointment reminders, diagnostic test results and information that may affect the health and wellbeing of my
pet, such as drug or pet food recalls. I may withdraw my consent at any time by contacting MVH in writing.

In accordance with the Privacy Act, I understand my rights for privacy and that personal information will not be released without my consent. I consent and authorize the disclosure of necessary personal and medical information required for the ongoing veterinary care of my pet, when communicating with other veterinarians, specialists and other relevant third parties.
Please indicate if you agree with the above statement:*

YES, I consentNO, I do not consent

PHOTO/VIDEO RELEASE
McKnight Veterinary Hospital (MVH) enjoys sharing our patient’s photos and stories within our hospital and online. We would love your permission to share your pet’s image and story. Sharing stories is a fun way to assist us in educating other pet owners about pet health.

Please note: photos and/or video recordings may be required to document your pet’s medical condition, and therefore may be used as an important aspect of your pet’s legal medical record. This release refers to public use of photos/video recordings only.

Help us by reviewing the statement’s below:

I grant MVH, its representatives, and employees the right to take photos/video recordings of my pet, and to copyright, use, or publish my pet and my pets story in print and/or electronically including, but not limited to social media, publicity, advertising, online content, and for client education purposes.
Please state if you agree/disagree with the above statement*

I Agree with the aboveI Disagree (Please do not share my pet's photo for their story)
Signature*

Clear
I understand that MVH is not responsible for any expense or liability incurred as a result of my pet(s) participation in any photos and/or video recordings.

I may withdraw my consent at any time by contacting McKnight Veterinary Hospital in writing.

ACKNOWLEDGMENT REGARDING PAYMENT
I understand full payment is due at the time services are rendered. If I am unable to pay in full, I must notify MVH immediately prior to treatment. Should my pet be hospitalized, I will receive an itemized treatment plan. I understand I must leave a deposit of the high end of the listed amount on the treatment plan. Accepted payment forms are cash, credit card, (MasterCard and Visa) and debit card.
Signature*

Clear
Should be Empty: