New Client Registration Form

Primary Account Information

Name*

First Last

Address*

Street Address Address Line 2 City ZIP Code

Phone*

Cell Phone*

Email*

Spouse or Secondary Account Name

Spouse or Secondary Account Cell

Pet's Information

Pet's Name*

Breed*

Color*

Sex*

Birthday (Age)*

Add a 2nd pet?*

Yes
No

2nd Pet's Information

Pet's Name

Breed

Color

Sex

Birthday (Age)

Add a 3rd pet?

Yes
No

3rd Pet's Information

Pet's Name

Breed

Color

Sex

Birthday (Age)

Add a 4th pet?

Yes
No

4th Pet's Information

Pet's Name

Breed

Color

Sex

Birthday (Age)

Additional Information

Name of Previous Clinic

Previously diagnosed problems of allergies?

Prior Surgeries (excluding spay or neuter)

Please read the following regarding the personal information protection and electronic documents act:
We at Murdoch Veterinary Clinic respect your right to privacy and will not collect, use or disclose any personal information regarding you or your pet without your consent. The information you provide is for clinic use only. The only time the information you provide may be shared would be in the case of referral or consultation with an outside veterinarian and only with your permission. As medical records are a legal document we do however, require your information in order to provide service. Please indicate below whether or not you will permit us to disclose information:

Consent*

I hereby consent to Murdoch Veterinary Clinic collecting, using and disclosing personal information about me. This information is intended for use in our local clinics promotional materials where photos may be used.
I prefer that Murdoch Veterinary Clinic not collect, use or disclose personal information about me

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Primary Account Information

Pet's Information

2nd Pet's Information

3rd Pet's Information

4th Pet's Information

Additional Information

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