Centre Street Animal Hospital
Thornhill, Ontario
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Home
About Us
Meet Our Team
Services
Pet Nutrition
Pet Dentistry
Examinations and Vaccinations
Laser Surgery
Laser Therapy
Blog
Video Blog
Contact Us
Virtual Tour
Home
About Us
Meet Our Team
Services
Pet Nutrition
Pet Dentistry
Examinations and Vaccinations
Laser Surgery
Laser Therapy
Blog
Video Blog
Contact Us
Virtual Tour
New Client Form
New client sign in - Please tell us about you
Name
*
First
Last
Salutation
*
Mrs.
Ms.
Miss
Mr.
Dr.
Other
Salutation Other
Home Phone
*
Work Phone
Cell Phone
Email
*
Emergency Phone (secondary contact)
*
Address
*
Street Address
Address Line 2
City
Alberta
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Manitoba
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Nova Scotia
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Province
Postal Code
Please tell us about your pet(s)
How many pets do you wish to register?
1
2
3
Pet Name (1)
*
Breed (1)
*
Sex (1)
*
Birthdate (1)
*
MM slash DD slash YYYY
Spay or Neutered? (1)
*
Previous Vaccinations? (1)
Colour (1)
Pet 2 Information
Pet name (2)
*
Breed (2)
*
Sex (2)
*
Birthdate (2)
*
MM slash DD slash YYYY
Spay or Neutered? (2)
*
Previous Vaccinations? (2)
Colour (2)
Pet 3 Information
Pet name (3)
*
Breed (3)
*
Sex (3)
*
Birthdate (3)
*
MM slash DD slash YYYY
Spay or Neutered? (3)
*
Previous Vaccinations? (3)
Colour (3)
Please tell us how you heard of us
Please select all that apply.
Hospital sign
Word of mouth
Online search for convenient location
Online reviews
Social media
Friend/Family member
50/50 promotion
Other (Please specify below)
Other - please let let us know
Whom should we thank for the referral?
Policies and Permissions
Scheduling Policy
*
I agree to the Scheduling Policy
1. Clients are asked to arrive at least 5 minutes before their scheduled appointment time.
2. If a client is running late it is expected for them to call to let the clinic know. Every effort will be made to still accommodate the patient to the best of our ability without inconveniencing other clients. However, if a client is running more than 10 minutes late the appointment will need to be rescheduled.
3. If a client is unable to attend an appointment, 24 hours notice is required. If there is less than 24 hours notice given or the client does not attend a scheduled appointment a late cancellation/no-show fee will be added to their account.
Personal Information Policy
*
I agree to the Personal Information Policy
I understand that Centre Street Animal Hospital has a personal information policy in accordance with the requirements of the Personal Information Protection and Electronic Documents Act.
I am consenting to the collection, use and disclosure of my personal information (such as my home phone number, email address and street address) in accordance with the purposes set out in the Policy, which include the following:
1. Maintaining complete and accurate client files, and complying with the requirements of the College of Veterinarians of Ontario, the Veterinarians Act and regulations under the Act;
2. Providing goods and services to veterinary clients, including contacting clients to schedule appointments and follow up on patient treatment, billing for goods and services and notifying clients about new services and promotional offers;
3. Communicating and working with third parties providing veterinary medical or other services to clients, including other veterinary facilities and insurance companies which may pay for all or part of the cost of such services.
I understand that:
1. My personal information will not be used or disclosed for purposes other then those for which it was collected, except with my consent, or except where use or disclosure is required by law;
2. I have the right to view my personal information and have it amended, if inaccurate or incomplete;
3. A copy of the Policy will be provided on request.
Do you grant us permission to display images and videos of your pet(s) on our public social media accounts (Facebook, Instagram, Youtube, Twitter, etc)?
*
Yes
No
Signature
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Date
*
MM slash DD slash YYYY
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