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Contact
Home
About Us
Meet Our Team
Veterinarians
Registered Veterinary Technologists
Veterinary Assistants
Administrative Support Staff
Gallery
Our Services
Canine
Feline
Equine
Therapeutic Laser
Regenerative Medicine
Urgent Care
Pet Owners
New Clients
New Client Registration Form
Request Appointment
Client Policies
Payment Options
Online Forms
Download Our App
Murdoch’s Furry Friends Coloring Book
Resources
Veterinary Resources
Equine Information
Contact
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
*
-
Female (Intact)
Female (Spayed)
Male (Intact)
Male (Neutered)
Birthday (Age)
*
Add a 2nd pet?
*
Yes
No
2nd Pet's Information
Pet's Name
Breed
Color
Sex
-
Female (Intact)
Female (Spayed)
Male (Intact)
Male (Neutered)
Birthday (Age)
Add a 3rd pet?
Yes
No
3rd Pet's Information
Pet's Name
Breed
Color
Sex
-
Female (Intact)
Female (Spayed)
Male (Intact)
Male (Neutered)
Birthday (Age)
Add a 4th pet?
Yes
No
4th Pet's Information
Pet's Name
Breed
Color
Sex
-
Female (Intact)
Female (Spayed)
Male (Intact)
Male (Neutered)
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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