New Client/Patient Information Date* MM slash DD slash YYYY Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone Number*Home Phone NumberWork Phone NumberEmail* Date of scheduled appt* MM slash DD slash YYYY Do you permit us to communicate medical and appointment related information about your pet via email?* Yes No Alternate Contact Person and Number (Emergencies)Pet’s Name*Breed*Color/Markings*Birth date/estimated age*Sex* M F Spay/Neutered* Yes No Date of last vaccines*Tattoo/Microchip*Previous Veterinary Hospital*Do you have another pet?* Yes No Pet’s NameBreedColor/MarkingsBirth date/estimated ageSex M F Spay/Neutered Yes No Date of last vaccinesTattoo/MicrochipPrevious Veterinary HospitalPAYMENT POLICYPayment is due at the time services are rendered. Hospitalized patients will not be released without payment. We will prepare a written estimate prior to treatment if requested. Please ask the technician or doctor. If you are unable to meet our payment terms, you are obliged to notify us prior to treatment.We accept the following forms of payment.* Cash Debit card MasterCard Visa WE DO NOT ACCEPT CHEQUESI have read the above and understand the payment policy of Animal Clinic. (SIGN HERE)*Date* MM slash DD slash YYYY Animal Clinic complies with the Personal Information Protection Act, which came into effect in Alberta on January 1, 2004. We are committed to respecting the privacy rights of all of our clients by ensuring their information is collected, used, and disclosed in an appropriate manner.Consent to Collect, Use, and Disclose Personal InformationI authorize Animal Clinic to collect, use, and disclose my personal information for the following purposes: to maintain current and accurate client files; to communicate with you in order to provide ongoing veterinary medical services to your pet(s); to re-unite you with your pet in the event that they become lost; to disclose your personal information and pets' medical records to other veterinary practices for referral purposes or as requested by you; to generate internal statistical data that does not identify you personally; to meet legal and regulatory requirements; to collect your account or process bills on your credit card should you give consent to do so; to communicate with your emergency contact person should you be unavailable in an emergency; for other such purposes as may be determined by us, acting reasonably, or as is otherwise authorized or required by law.I understand that I may decline or object to having my personal information collected, used, or disclosed for the above purposes. I also understand that I may revoke this consent at any time by submitting a written notice.Signature*Date* MM slash DD slash YYYY Should you have questions regarding our collection, use, or disclosure of your personal information, please contact our Privacy Officer.Appointment Cancellation/No Show PolicyDowntown Animal Clinic, CalgaryOur goal is to provide quality individualized medical care in a timely manner. "No Shows" and late cancellations inconvenience those patients who are in need of medical treatment. We would like to remind you of our office policy regarding missed appointments.Cancellation of an AppointmentIn order to be respectful of the needs of other patients, please call 9th Ave Animal Clinic promptly if you need to cancel or reschedule your appointment. We appreciate at least 8 hours notification for appointments and more than 24 hours for surgeries. Your timely cancellation will help another client and their pet receive care. As a courtesy, our staff will call you 1-2 days in advance to confirm your appointment.No Show PolicyA "No Show" is someone who is not present at the time of their scheduled appointment/surgery and has not provided adequate notification. If you have historically "no-showed" for an appointment/surgery, you will be asked to leave a credit card number in order to book a new appointment. If you "no-show" you will be charged a non-refundable fee of $110. If you have any questions regarding this policy, please ask our staff and we will be glad to clarify your questions. We thank you in advance for your cooperation and understanding.Appointment Cancellation/No Show PolicyI acknowledge that I have been presented with the Appointment Cancellation/No Show Policy and that I understand the policy. Signature*Date* MM slash DD slash YYYY Printed Name* First Last PhoneThis field is for validation purposes and should be left unchanged.