New Client/Patient Information Date* Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Cell Phone Number*Home Phone NumberWork Phone NumberEmail* Date of scheduled appt* Do you permit us to communicate medical and appointment related information about your pet via email?*YesNoAlternate Contact Person and Number (Emergencies)Pet’s Name*Breed*Color/Markings*Birth date/estimated age*Sex*MFSpay/Neutered*YesNoDate of last vaccines*Tattoo/Microchip*Previous Veterinary Hospital*Do you have another pet?*YesNoPet’s NameBreedColor/MarkingsBirth date/estimated ageSexMFSpay/NeuteredYesNoDate 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.*CashDebit cardMasterCardVisaWE DO NOT ACCEPT CHEQUESI have read the above and understand the payment policy of Animal Clinic. (SIGN HERE)*Date* 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* 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 $98. 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* Printed Name* First Last PhoneThis field is for validation purposes and should be left unchanged.