New Patient FormLangley Animal Clinic2022-04-27T04:37:35+00:00 New Patient Form PATIENT DETAILS (PET):Name of Pet: Pet: Dog Cat Other Other (please specify): Breed: Colour: Age:Date of Birth (mm/dd/yyyy): MM slash DD slash YYYY PLEASE CHECK ONE OF THE FOLLOWING: Female Spayed Female Intact Male Neutered Male Intact INSURANCE PROVIDER: No Yes Please specify Policy Number (if known): CLIENT DETAILS (OWNER):Name First Last LandlinePhoneEmail Enter Email Confirm Email *An e-mail is needed to send medical records & payment information, you will not receive any spam from LAC.Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code SECONDARY CONTACT (friend or family member that may bring the animal in):Name First Last PhoneConsent Yes, you may take photos of my pet*By listing the party above, you are authorizing them to make medical/financial decisions for the patient. I hereby grant permission to Langley Animal Clinic to potentially use my pet’s photo and story for posting on social media and printed materials. I acknowledge that no personal or private details will be released. No, please do not take photos of my petHow did you hear about us? Please NotePayment is due as services are rendered. The Langley Animal Clinic does not extend credit or provide payment plans. We accept cash, Debit, Visa Mastercard and American Express. No cheques are acceptedDate MM slash DD slash YYYY Signature 38436Δ