Online Forms

At Virden Animal Hospital, we offer patient forms online so you can complete them in the convenience of your own home or office. Fax us your printed and completed forms or you may bring them during your visit.

Owner / Caregiver

Please provide the information below as completely as possible. All information is strictly confidential.

Owner / Caregiver**(Required)

Partner / Spouse

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Pet Information

Pet's Name(Required)

First Last

Species(Required)

Name

First Last

Breed(Required)

Age / Birthdate(Required)

Gender(Required)

Color / Markings

Spayed / Neutered?

Yes

Are Vaccinations Current?

Yes

Referral Information

Referral Veterinarian

Clinic Name

Phone(Required)

Do you have X-rays

Notes

Statement Of Ownership

By checking below you certify that you are the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed.

Confirmation(Required)

Yes

Comments

Consent(Required)

I agree to the Terms and Conditions.

Terms and Conditions

At Virden Animal Hospital, we are committed to providing our clients with exceptional service. Providing this service involves the collection, use and disclosure of some personal information about our clients. Protecting their personal information is one of our highest priorities. While we always respected our clients’ privacy and safeguarded their personal information, under The Personal Information Protection and Electronic Documents Act (PIPEDA) we have strengthened our commitment to protecting personal information under, The Personal Information Protection and Electronic Documents Act (PIPEDA).

We will inform our clients of why and how we collect, use and disclose their personal information, obtain their consent where required, and only handle their personal information in a manner that a reasonable person would consider appropriate in the circumstances. The Personal Information Protection and Electronic Documents Act (PIPEDA), outlines the principles and practices we will follow in protecting clients’ personal information. Our privacy commitment includes ensuring the accuracy, confidentiality and security of our clients’ personal information and allowing our clients to request access to and correction of their personal information.

Definitions

Personal Information – means information about an identifiable individual (examples: name, address, phone number). Personal information does not include contact information (described below).

Contact information – means information that would enable an individual to be contacted at a place of business and includes name, position name or title, business telephone number, business address, business email or business fax number. Contact information is not covered by this policy or PIPEDA.

Policy 1 – Collecting Personal Information

1.1 Unless the purposes for collecting personal information are obvious and the client voluntarily provides his or her personal information for those purposes, we will communicate the purposes for which personal information is being collected, either orally or in writing, before or at the time of collection.

1.2 We will only collect client information that is necessary to fulfill the following purposes:

To verify identity
To manage client accounts
To provide veterinary products
To provide veterinary services
To send out reminders of services
To meet our veterinary medical association’s regulatory requirements
To ensure a high standard of service to our clients

Policy 2 – Consent

2.1 We will obtain client consent to collect, use or disclose personal information (except where, as noted below, we are authorized to do so without consent).

2.2 Consent can be provided (orally, in writing, electronically or through an authorized representative) or it can be implied where the purpose for collecting using or disclosing the personal information would be considered obvious and the client voluntarily provides personal information for that purpose.

2.3 Consent may also be implied where a client is given notice and a reasonable opportunity to opt-out of his or her personal information being used for mail-outs and the client does not opt-out.

2.4 Subject to certain exceptions (e.g., the personal information is necessary to provide the service or product, or the withdrawal of consent would frustrate the performance of a legal obligation) clients can withhold or withdraw their consent for Virden Animal Hospital, to use their personal information in certain ways. A client’s decision to withhold or withdraw their consent to certain uses of personal information may restrict our ability to provide a particular service or product. If so, we will explain the situation to assist the client in making the decision.

2.5 We may collect, use or disclose personal information without the client’s knowledge or consent in the following limited circumstances:

When the use of personal information is permitted or required by law
When the personal information is available from a public source (e.g. at telephone directory)
When we require legal advice from a lawyer or regulatory association
For the purpose of collecting a debt
To protect ourselves from fraud

Policy 3 – Using and Disclosing Personal Information

3.1 We will only use or disclose client personal information where necessary to fulfill the purposes identified at the time of collection or for the purpose reasonably related to purposes such as:

To conduct client surveys in order to enhance the provision of our services.
To contact our clients about products or services that may benefit their pets.
To contact our clients in the event of a medical alert concerning their pet

3.2 We will not use or disclose client personal information for any additional purpose unless we obtain consent to do so.

3.3 We will not sell client lists or personal information to other parties.

Policy 4 – Retaining Personal Information

4.1 If we use client personal information to make a decision that directly affects the client, we will retain that personal information for at least one year so that the client has a reasonable opportunity to request access to it.

4.2 Subject to policy 4.1, we will retain client personal information only as long as necessary to fulfill the identified purposes or a legal or business purpose.

Policy 5 – Ensuring Accuracy of Personal Information

5.1 We will make reasonable efforts to ensure that client personal information is accurate and complete where it may be used to make a decision about the client or disclosed to another organization.

5.2 Clients may request correction to their personal information in order to ensure its accuracy and completeness. A request to correct personal information must be made in writing and provide sufficient detail to identify the personal information and the correction being sought.

5.3 If the personal information is demonstrated to be inaccurate or incomplete, we will correct the information as required and send the corrected information to any organization to which we disclosed the personal information in the previous year. If the correction is not made, we will note the clients’ correction request in the file.

Policy 6 – Securing Personal Information

6.1 We are committed to ensuring the security of client personal information in order to protect it from unauthorized access, collection, use, disclosure, copying, modification or disposal or similar risks.

6.2 The following security measures will be followed to ensure that client personal information is appropriately protected:

Client files on computers are kept safe with passwords and firewalls are monitored daily.

6.3 We will use appropriate security measures when destroying client’s personal information such as shredding documents and deleting electronically stored information.

6.4 We will continually review and update our security policies and controls as technology changes to ensure ongoing personal information security.

Policy 7 – Providing Clients Access to Personal Information

7.1 Clients have a right to access their personal information, subject to limited exceptions (examples include: solicitor-client privilege or health and safety concerns)

7.2 A request to access personal information must be made in writing and provide sufficient detail to identify the personal information being sought.

7.3 Upon request, we will also tell clients how we use their personal information and to whom it has been disclosed if applicable.

7.4 We will make the requested information available within 30 business days or provide written notice of an extension where additional time is required to fulfill the request.

7.5 A minimal fee may be charged for providing access to personal information. Where a fee may apply, we will inform the client of the cost and request further direction from the client on whether we should proceed with the request.

7.6 If a request is refused in full or in part, we will notify the client in writing, providing the reasons for refusal and the recourse available to the client.

Policy 8 – Questions and Complaints: The Role of the Privacy Officer or designated individual

8.1 The Office Manager is responsible for ensuring Virden Animal Hospital, compliance with this policy and the Personal Information Protection and Electronic Documents Act (PIPEDA) Policy

8.2 Clients should direct any complaints, concerns or questions regarding Virden Animal Hospital, compliance in writing to the Office Manager. Contact information for Virden Animal

Hospital Office Manager:

Virden Animal Hospital PO Box 1390 Virden, MB R0M 2C0

Owner / Caregiver

Pet Information

Referral Information

Statement Of Ownership

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