Clinic Registration

"*" indicates required fields

Client Information

First Name*

Last Name*

Street Address*

Address Line 2

City/Community*

Postal Code*

Province*

Phone*

Email*

Are You a Band Member? If So, Which Band?*

Patient Information

Pet Name*

Species*

Dog

Cat

Is Your Pet Already Spayed or Neutered?*

Yes

Sex*

Male

Female

Has Your Pet Ever Received Vaccinations? If So, What Was The Last Date They Received Vaccines and Where Was This Done?*

Date Of Birth / Age*

Breed*

Colour*

Treatments Requested*

Select All That Apply

Please Describe*

Consent

Consent*

I, the undersigned owner or owner’s agent, consent to the examination of my pet by North of 50 Veterinary Remote Mobile and, after consultation with me, consent to the treatment of my animal.

Privacy Policy: North of 50 Veterinary Remote Mobile will collect information about your animal’s history, physical condition, and care needs to assess their health, discuss available options with you, and provide the veterinary services you choose. This information will not be shared with anyone outside of North of 50 Veterinary Remote Mobile, Precious Paws Rescue, or the leadership of the Nation hosting the clinic, and only for the purpose of coordinating and continuing care.

If your pet is not already microchipped, they may be microchipped for permanent identification as part of the services provided during this clinic.

I confirm that I am the owner, or an authorized agent, of the animal described above and that I am over 18 years of age. I have had the procedures explained to me and understand that there is no guarantee as to the outcome or reaction of my pet to any treatment or procedure undertaken. I hereby consent to and authorize the above procedures.

I have read, or have had read to me, and understand this consent form.

I agree

Signature*

Print Name*

Date*