New Client Registration Form

Welcome! We would like to take this opportunity to welcome you to our practice and thank you for choosing our clinic to provide care for your family. We value our relationship with you and believe that the best relationships are based on understanding. The purpose of this form is to obtain the relevant personal information about you and your pet(s) necessary for our office to provide the required services today and in the future. If you have any questions or concerns, please feel free to ask any member of our staff.

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First and Last names of Owner(s) *

Street Address: *

City and Province: *

Postal Code *

Email address: *

Primary Phone Number: *

Secondary Phone Number (optional):

Please check the following boxes to acknowledge your understanding *

I am aware that by disagreeing with any of the following statements I am declining the terms of service for Range Road Veterinary Clinic

1. I hereby authorize the veterinarian(s) to examine, prescribe for and/or treat my pet(s). *

Yes
I disagree and decline services

2. I acknowledge that Range Road Veterinary Clinic protects my information in accordance with the Alberta Personal Information Protection Act. The personal information you have provided to us will not be shared without your written consent unless it pertains directly to necessary services required for your pet(s) such as transfer to emergency care or further diagnostic tests. By acknowledging this you agree to Range Road Veterinary Clinic collecting, using and disclosing the personal information provided as indicated. *

Yes
I disagree and decline services

3. I assume responsibility for all charges incurred with the care of my animal. I understand that these charges will be paid prior to the discharge of my pet(s) and that a deposit may be required for surgical procedures. We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor. *

Yes
I disagree and decline services

4. I understand and agree that payment is due in full on the day of my appointment at the time services are rendered. We do not accept personnel checks. *

Yes
I disagree and decline services

5. I understand that Range Road Veterinary Clinic is a small business, and are not able to provide loans for services. We can provide contact information for third-party lending services if required. All loans must be verified by RR staff prior to services being rendered. *

Yes
I disagree and decline services

6. I understand that the time booked for my appointment has been reserved for me. Range Road will contact you prior to remind you of the date and time. In consideration of our staff and other patients, we requires at least 24 hours or one business day notice on all cancellation or rescheduling of appointments. In the event of multiple no-shows or late cancellations, a deposit may be required to secure future appointments. Some surgical procedures will require a deposit at the time of booking. This deposit will be returned if the cancellation policy is respected. *

Yes
I disagree and decline services

7. Range Road staff is committed to creating and maintaining a positive, respectful and professional practice. We will not tolerate verbal abuse, including rude or condescending words or actions towards our staff. Discrimination and harassment will not be tolerated. We reserve the right to not provide services to aggressive or abusive guests. Thank you for working with us to create a positive experience for all. *

Yes
I disagree and decline services

By signing below I acknowledge that I have read and understood the above statements *

Todays Date (mm/dd/yyyy): *

As a new client to the Range Road Veterinary Clinic we want you to know that our goal is to provide every option for the best care of your pet. We want you to have options so you can choose what is best for your family. We look forward to providing you with veterinary care. If you have any questions or concerns, please feel free to ask any of our staff.

VETERINARY DICTATION SOFTWARE CONSENT. Veterinary Dictation Software is used to record and transcribe conversations during veterinary visits. The Dictation Software is utilized by veterinary service providers and clinics (“we” or “us” or “our”) to enhance the quality of services provided and to assist in effective and accurate documentation of pet information, symptoms, assessments or examinations and treatment plans. If pet owners provide personal information during veterinary visits, this information would also be recorded and transcribed through use of Veterinary Dictation Software. We do not use or disclose any personal information or other information outside of what is necessary to provide the services to your pet, and always in accordance with our privacy policies and applicable privacy laws. My decision to consent to use of veterinary dictation software during veterinary visits for my pet(s) at Range Road Veterinary Clinic is completely voluntary. *

I consent and agree that Range Road may record and transcribe our conversations during my clinic visits with the veterinarian(s).
I DO NOT consent to dictation software being used during my clinic visits with the veterinarian(s).

If you decide at a later date to revoke/provide consent, please will let a Range Road staff member know.

How did you hear about us? *

If you were referred to us, who can we thank?

Which Veterinary Clinic(s) has your pet been to previously?

If you would like us to obtain a copy of your pets medical history, please complete our Medical Record Request form.

Do you authorize pictures of your pets to be taken and shared on our clinic webpage, newsletters and social media? *

Do you have Pet Insurance? If so please provide the company name and Policy Number below:

As a courtesy to you, our staff will complete the veterinary portion of your insurance claim form and submit to your insurance for your reimbursement. Please provide the clinic with your filled and signed insurance form. Please leave the date blank as this form will be used for all of your visits. If your information, insurance provider or any information on the form changes, please provide the clinic with an updated form. Please be advised that insurance is a contract between you and your insurance company. Under the Privacy Act, the majority of insurance companies will not provide our office with any details regarding your coverage. We cannot influence how much of our fees your insurance will cover. Your insurance benefits are determined by your individual policy and carrier. Our objective as animal health care providers is to diagnose any treatment required according to each patient’s particular needs. We do not know if your insurance will cover the treatment we diagnose, as this is only outlined in your policy. You will be responsible for fees incurred and reimbursed by your insurance as they deem eligible.

PET 1: Your Pets Name: *

Sex of Pet: *

Age of Pet: *

If known, please feel free to provide your pets birthday or birth year!

Species of Pet: *

Breed of Pet: *

Colour of Pet: *

PET 2: Your Pets Name: (if you have only one pet feel free to submit the form now)

Sex of Pet:

Age of Pet:

If known, please feel free to provide your pets birthday or birth year!

Species of Pet:

Breed of Pet:

Colour of Pet:

PET 3: Your Pets Name: (if you have only two pets feel free to submit the form now)

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Sex of Pet:

Age of Pet:

If known, please feel free to provide your pets birthday or birth year!

Species of Pet:

Breed of Pet:

Colour of Pet:

PET 4: Your Pets Name: (if you have only 3 pets, feel free to submit the form now. If you have more than 4 pets please let us know at the time of your next appointment and we can add them to your file)

Sex of Pet:

Age of Pet:

If known, please feel free to provide your pets birthday or birth year!

Species of Pet:

Breed of Pet:

Colour of Pet:

New Client Registration Form

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