New Client Application Form – Chippawa Animal Hospital

Owner #1*

First name Last name

Address*

Street Address Address Line 2 City Province Postal Code

Primary Phone Number*

Alternate Phone Number

Email*

How did you hear about us?

Would you like to add a secondary owner?*

Yes
No

Owner #2*

First name Last name

Address*

Street Address Address Line 2 City Province Postal Code

Primary Phone Number*

Alternate Phone Number

Email

Authorized Representative*

This person is authorized to make financial and medical decisions for your pet(s). Restrictions to financial and medical decisions must be specifically stated prior to the time an authorized representative is required to make them on your behalf.

First name Last name

Phone Number*

Would you like to add a second authorized representative?*

Yes
No

Authorized Representative*

This person is authorized to make financial and medical decisions for your pet(s). Restrictions to financial and medical decisions must be specifically stated prior to the time an authorized representative is required to make them on your behalf.

First name Last name

Phone Number*

Consent for financial/medical decisions is required from:*

Owner #1
Owner #2
Either owner #1 or #2
Both owners #1 and #2

Patient #1*

Name

Species*

Canine
Feline

Breed*

Colour*

Date of Birth*

MM

DD

YYYY

Sex*

Male
Female

Is your pet neutered/spayed?*

Yes
No

Previous Veterinary Hospital*

(N/A if not applicable)

Would you like to add another pet?*

Yes
No

Patient #2*

Name

Species*

Canine
Feline

Breed*

Colour*

Date of Birth*

MM

DD

YYYY

Sex*

Male
Female

Is your pet neutered/spayed?*

Yes
No

Previous Veterinary Hospital*

(N/A if not applicable)

Would you like to add another pet?*

Yes
No

Patient #3*

Name

Species*

Canine
Feline

Breed*

Colour*

Date of Birth*

MM

DD

YYYY

Sex*

Male
Female

Is your pet neutered/spayed?*

Yes
No

Previous Veterinary Hospital*

(N/A if not applicable)

Would you like to add another pet?*

Yes
No

Patient #4*

Name

Species*

Canine
Feline

Breed*

Colour*

Date of Birth*

MM

DD

YYYY

Sex*

Male
Female

Is your pet neutered/spayed?*

Yes
No

Previous Veterinary Hospital*

(N/A if not applicable)

Clients Rights and Responsibilities*

Clients Rights and Responsibilities

At Chippawa Animal Hospital our mission is to help the pets we see each day live long, happy and healthy lives. To do this we provide up-to-date, high quality, compassionate veterinary care.
We treat our clients like family and their pets like they're our own. We do all this with a focus on being worthy of trust and providing an experience free of fear.

We believe that clear and defined expectations and open communication are important to fulfill our purpose.

As a client you have the right to...
1. Accurate, clear, and objective information about your pet's health.

2. Expect and receive your pet's diagnosis, prognosis, and appropriate treatment as determined by our capabilities and the resources available to us.

3. Be presented with a range of care options in terms you understand.

4. Participate in decisions regarding your pet's care.

5. Accept or decline tests or treatment based on risks and benefits.

6. Receive explanations about our team's decisions which would include reasons why our staff may decline to provide a specific service.

7. Be informed of the costs of recommended veterinary services in the form of a treatment plan.

8. Have your questions and concerns thoughtfully considered.

9. Considerate, respectful, compassionate care and communication from all members of our team.

10. Discrimination-free veterinary care.

11. Receive respect for your time with prompt communication regarding any anticipated delays related to your appointment.

12. Have personal and medical information held in confidence.

13. Have copies or summaries of medical records provided upon your request.

14. Be provided with contact information and office hours for this animal hospital or veterinary emergency services for continuing care and treatment.

As a client your responsibility is to…
1. Provide relevant, accurate and complete medical and behavioral information about your pet.

2. Read and understand any consent forms and estimates that you sign.

3. Ask questions about:
- Your pet’s health status and prognosis.
- Any recommended diagnostic or treatment options.
- Next steps if unclear.
- Instructions or information we provide if you do not understand.

4. Work collaboratively with your pet’s care team to develop and perform the agreed-upon treatment plan, including any necessary follow-up visits and at-home care.

5. Inform us if you have any need for assistance, so that we can help you.

6. Let our team know if you have any concerns about your pet’s care so that we may take steps to improve your experience.

7. Honor your financial obligations and the payment policies agreed upon.

8. Accept that our team will do their best for your pet and may not be able to provide some services or accommodate all requests. We will give advice to the best of our knowledge which is current, scientifically proven and unbiased.

9. Demonstrate consideration and respect toward all members of our team, other clients and patients. Please respect our veterinary medical training and experience.

10. Refrain from making discriminatory complaints or service requests.

11. Accept that veterinarians are legally and ethically bound to provide veterinary services strictly under the terms of a current Veterinarian-Client-Patient relationship (V-C-P-R).

12. Arrive to appointments on time or call ahead if you are going to be late or need to cancel. Understand that patients’ needs can be unpredictable, and show patience with delays.

13. Keep your personal information updated as to your (owner’s and authorized persons) addresses, phone numbers, emails.

14. Be aware of the consequences for any behavior inconsistent with this document, including potential termination of the Veterinary-Client-Patient Relationship.

15. Expect that referral to another facility will be necessary for after-hours care and sometimes during our regular hours should our schedule not allow us to accommodate your pet in a timely fashion. Please accept that our “rest” time is essential to our own health, career longevity and ability to perform our jobs without suffering compassion fatigue. Do not call or contact our staff after hours for medical advice.

Scheduling Policy
Chippawa Animal Hospital sees patients by appointment only. “Walk-ins” will be triaged (a rapid assessment, usually performed by a Registered Veterinary Technician to determine if your pet’s condition is a life threatening emergency) and you may be referred to the Niagara Veterinary Emergency Clinic. We are not an emergency hospital but may have availability to treat urgent medical issues with prior arrangements. Please call us at 905-295-8111 before bringing in your pet. We set aside appointments each day for urgent medical issues, but if our appointment schedule is full and we are already providing urgent care for other patients, we may be unable to assist you.
Appointments can be arranged by phone or email (info@chippawavet.com). Our Veterinarians are not available for consultations outside of scheduled appointments and subsequent follow-ups. If you would like to speak to a Veterinarian directly about an issue, please schedule a consultation.

Office Visit Protocol
Upon your arrival, please call in to the receptionist using your cell phone. We will indicate if there is a wait. One of our Veterinary Technicians will escort you and your pet into an examination room as soon as we are ready. Patients treated by another Veterinarian may be called before you when their Veterinarian is available, not because they are taken out of turn. When you go to the assigned examination room, our technician may perform a brief “vital signs” examination. The Veterinarian will complete the examination and offer further procedures if these seem indicated. Please ask questions and discuss your pet’s health as well as costs at this time.

Payment of Bills
Our policy is that a client is to keep their balance at zero. This means payment is due at the time of examination and treatment. Overdue accounts have interest accrued to them. Failure of a client to make payment of an overdue account or to otherwise communicate with us will result in prompt legal action.
We will keep you informed of the costs of services in advance in the form of a treatment plan. Medical circumstances may change unexpectedly, but we will inform you of how those changes may influence your financial obligations.

Changing Appointments and Late Arrivals
If you need to change an appointment, try to reschedule it as soon as possible. If you miss an appointment, we expect you to call, as we have reserved the doctor’s time for you. We reserve the right to withdraw the privilege of being a client in our office to those who cannot respect this.
If you are going to be more than 10 minutes late for an appointment, we may ask you to wait for another opening in the schedule, or to reschedule your appointment for a different day. We feel that it is unfair to delay other clients who arrive on time at their scheduled appointment.
Appointments cancelled within less than 24 hours of the scheduled start time will result in a requirement to prepay a deposit when you schedule your pet’s next appointment. If this prepaid appointment is kept, your deposit will be applied to the invoice. If this prepaid appointment is not kept, your deposit will be forfeit.

Upsets
We are here to serve you. Please speak with your Veterinarian about any upsetting matters, i.e. long wait times, staff insensitivity, confusion about treatment, etc. We see your comments as helping us to help you and others.

Hours
Your Veterinarian has specific office hours. The receptionist will schedule your appointment accordingly. Our clinic hours are 8:00 am to 5:00 pm Monday to Friday. Emergencies may be referred to the Niagara Veterinary Emergency Clinic during the day, and always at night (905-641-3185).

Charges
There will be an examination fee for each office visit, as well as for each re-examination and treatment.

Pet Insurance
Many pets have insurance coverage. This is an agreement between you, the client, and the insurance company, not between the insurance company and your Veterinarian. Therefore, it is your responsibility to find out your exact coverage and submit receipts from this office to your company for reimbursement.

Mutual Respect Policy
Questions and concerns will be handled by our team of highly qualified and knowledgeable Client Service Representatives, Registered Veterinary Technicians, and Veterinarians. All team members should be treated with the same respect as that provided to our Veterinarians. If team members are relaying advice or information, they have been authorized and trained by the Veterinarians to do so.

Medical Records and a Veterinary-Client-Patient Relationship (VCPR)
By law, in order to provide advice to you and care for your pet, we must establish a VCPR. This means, among other things, that we have physically examined the patient in question within the past 12 months. This is important to note when requesting refills of prescription medication or food, or if you are asking questions regarding your pet's health. We cannot provide these services if we do not have a legally valid VCPR. Booking of the appointment does not mean that a VCPR has been established. A VCPR requires an agreement on the scope of services to be provided by the Veterinarian, and the understanding that those services will only be provided in accordance with the standards of the profession. Chippawa Animal Hospital provides anesthesia, surgery, dentistry, laboratory testing, x-rays, ultrasound, medications, vaccinations, and euthanasia. We do not provide critical care, chemotherapy, isolation facilities, laser therapy, MRI, CT, or rehabilitation therapy.
You are entitled to a complete and thorough copy of your pet’s medical records at any time. Pet records will be transferred at your request within 2 business days. Record transfer may only be requested by the listed owner(s) on the patient’s account.

Discontinuing the VCPR can be due to…
1. Any form of verbal abuse or threatening behavior toward the staff of the clinic.

2. Persistent non-adherence to recommended treatment plans.

3. Differences in philosophy as to the approach taken to diagnose and treat the pet.

4. Unreasonable demands for unnecessary medications and services; requesting illegal or unethical actions.

5. Non-payment of fees owed for services rendered.

6. Length of time since the pet was last seen.

Discontinuing the VCPR will be noted in the record by…
1. A date after which services will no longer be rendered.

2. Indication that until that date, how emergency services will be provided to the pet.

3. Information about the transfer of medical records.

I have read and agree to the Clients Rights and Responsibilities.

Privacy Policy*

Chippawa Animal Hospital agrees that all client and practice related information will be kept confidential, and will only be used for the purposes for which it was provided. Chippawa Animal Hospital agrees not to disclose the client and practice information to any third party without your prior written consent.

Our personal information policy is in accordance with the requirements of the Personal Information Protection and Electronic Documents Act (PIPEDA). By checking below, I am consenting to the collection, use, and disclosure of my personal information (such as my home telephone number, address, and email) in accordance with the purposes set out in this Policy, which include the following:

1. Maintaining complete and accurate client files, and complying with the requirements of the College of Veterinarians of Ontario, Enhancing Professional Care for Animals Act and regulations under the Act.

2. Providing goods and services to veterinary clients, including contacting clients to schedule appointments and following up on patient treatment, billing for goods and services, and notifying clients about new services and promotional offers.

3. Communicating and working with third parties providing veterinary medical or other services to clients, including our pet health reminder system, other veterinary facilities and also insurance companies, which may pay for all or part of the cost of such services.

I understand that;

1. 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.

2. I have the right to view my personal information and have it amended, if inaccurate or incomplete.

3. A copy of our full Privacy Policy will be provided upon request.

I have read and agree to the privacy policy.

I’d like to receive telephone, email, or text updates for;

1. Reminders of important health care for my pet(s).

2. Updates on my pet’s current status while they are in hospital if needed.

3. Confirmation of appointment times.

4. Mass emails for news, announcements and seasonal changes (e.g. pet food recalls, product specials, webstore rebates).

I can unsubscribe to any of these Commercial Electronic Messages (CEM) at any time via phone or email.

Yes, I agree to receiving updates.