New Client Form






Thank you for giving us the opportunity to care for your pet. Please help us meet your needs by taking a moment to share some important information we will need to support your pet’s health today and in the future.

Please fill in all the below information for the primary account holder (person who will be primarily bringing your pet(s) in to see us and is authorized to make decisions regarding patient care):

Would you like us to contact you to make an appointment?

(If you choose no, we will wait to hear from you to schedule an appointment)

Information for the primary account holder:

Title:
First Name: *
Last Name: *

Address: *
City: *
Province: *
Postal Code: *

Phone #: *
Alternative Phone #:
Work Phone #:
Email: *

*By providing an email address and cell phone above, you consent to having your email and cell phone used for communication purposes – such as communication about your pet, reminders, newsletters, receipts, estimates and appointment reminders.

Please fill out the below information for the secondary account holder (optional):

First Name:
Last Name:
Primary Phone #:
Work/Alternate Phone #:

Relationship to primary account holder:

Authorized to make decisions regarding patient care:

How did you find us or hear about us?

Please fill out the information below regarding your pet(s):

Pet’s Name: * Type: * Breed: * Color: * Sex: * Date of Birth / Age: *

Date & Location of last vaccinations:

Does your pet have a tattoo or microchip?
# #

Are there any medical concerns that we should be aware of?

*We will gladly prepare a written estimate if you desire (please ask our doctor or receptionist). We accept Cash, Debit, Visa and Mastercard. No personal cheques please.

Please Read and Accept Terms:

Landing 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 Information

I, , authorize Landing Animal Clinic to collect, use, and disclose my personal information for the following purposes:

  • to maintain current and accurate medical records;
  • 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 you 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.

I Agree to the terms and conditions: *

Date: *

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