Patient Intake Form

Which practice would you like to register with?

Location

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CLIENT INFORMATION

Full Name *

Email Address * *

Address *

City *

Province *

Postal Code *

Phone Number

Secondary Phone Number

Emergency Contact (Full Name) *

Emergency Contact Phone Number *

Is anyone else authorized to make medical decisions regarding your pet? Please list their names:

Our Technicians and Animal Care Attendants are specially trained to assist the veterinarian while examining your pet. You are welcome to assist holding your pet during an examination if you wish, but must accept the responsibility for the risk if your pet bites or scratches you, or any of your family members, while at our hospital.

Would you like to hold your pet during the physical examination? *

Yes
No

Do you consent to being sent text messages regarding your pet? *

Yes
No

PATIENT INFORMATION

Pet's Name *

Species *

Breed *

Colour *

Date of Birth/Age *

Sex *

Spayed or Neutered? *

ID (e.g. tattoo or microchip #) *

Markings *

Known Allergies *

Please list any medical conditions that our team should be aware of: *

Please list any medications or supplements your pet is currently on: *

Is there another veterinarian we can call for more information? *

Do you have other pets in your household? *

Dogs
Cats
Other
No other pets

If 'Other', please specify:

PERSONAL INFORMATION POLICY CONSENT FORM

I understand that Woodbridge Animal Hospital Professional Corporation has a Personal Information Policy in accordance with the requirements of the Personal Information Protection and Electronic Documents Act. By signing below, I am consenting to the collection, use and disclosure of my personal information (such as my home telephone number and address) in accordance with the purpose set out in the policy, which includes the following:

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;
Providing goods and services to you, the client, including contacting clients to schedule appointments and follow-ups on patient treatment, billing for goods and services and notifying clients about new services and promotional offers.
Communicating and working with third parties providing veterinary medical or other services to you, such as other veterinary facilities and insurance companies which may pay for all or part of the cost of such services.

I understand that:

My personal information will not be used or disclosed for purposes other than those for which it was collected, except with my consent, or except where use or disclosure is required by law.
I have the right to view my personal information and have it amended, if inaccurate or incomplete.
We would like to use your email to send you newsletters, reminders, invoices, and medical updates, in order to cut down on paper use and be kind to the environment. By providing your email address, you consent to receive these emails.
I give Woodbridge Animal Hospital permission to disclose the types of vaccines given to my pet, and vaccine expiry dates to the following organizations that work with my pet:

Organizations *

Grooming Facilities
Boarding Facilities
Neither, please contact me before releasing any information to either of these organizations.

I give permission to Woodbridge Animal Hospital to post pictures of my pet(s) on the hospital's official social media accounts (@woodbridgeanimalhospital, etc.) *

Yes
No

Digital Signature (Type your full name) *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY * *

Patient Intake Form

Which practice would you like to register with?

CLIENT INFORMATION

PATIENT INFORMATION

PERSONAL INFORMATION POLICY CONSENT FORM

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