New Client Form | Roscoe Village Animal Hospital

Name*

First Last

Address*

Street Address City State ZIP Code

Do you give permission to RVAH to communicate with you by email?*

Yes
No

Do you give permission to RVAH to communicate with you by email and text message for appointment reminders?*

Yes
No

Primary Phone:*

Home
Mobile
Work

Alternative Phone:

Home
Mobile
Work

Email:*

Co-Owner Information

Co-Owner's Name

First Last

Co-Owner Phone:

Home
Mobile
Work

Co-Owner Email:

Previous Veterinary Hospital

Do you have pet insurance?*

Name of Pet Insurance Company

Policy Number

Your Pet's Information

Pet's Name:*

Pet's Date of Birth:*

Breed:*

Color:*

Gender:*

Is your pet neutered/spayed?*

Is your pet microchipped?*

Pet's Microchip Number

Does your pet become uncomfortable or aggressive with new people or animals? If Yes, please describe so we can create the safest and most comfortable experience for you and your pet.

Has your pet experienced any vaccine reactions?*

Second Pet (if applicable)

2nd Pet's Name

2nd Pet's Date of Birth:

2nd Pet's Breed:

2nd Pet's Color:

2nd Pet's Gender:

Is your 2nd pet neutered/spayed?

Is your 2nd pet microchipped?

2nd Pet's Microchip Number

Does your pet become uncomfortable or aggressive with new people or animals? If Yes, please describe so we can create the safest and most comfortable experience for you and your pet.

Has your pet experienced any vaccine reactions?

Referral Information

How did you hear of Roscoe Village Animal Hospital?*

If it s a personal referral, please let us know their name! As a token of our appreciation, a $20.00 credit will be applied to their RVAH account for this referral.

If you have already scheduled an appointment, please enter the appointment date here. Thank you.

Additional Comments:

Veterinary Care Authorization:I hereby authorize the veterinarian to examine, prescribe for, or treat for the above-described pet. I assume responsibility for all charges incurred in the care of my pet(s). I also understand that all professional fees are due at the time services are rendered. I verify that all the information provided is accurate.*

Yes
No

Cancellation Policy: I understand that if it is necessary to cancel a schedu-led appointment, we require that clients call at least 48 hours in advance. A $100 cancellation fee will be charged for any surgical or dental procedure that is canceled without the 48-hour advanced notification. Our policies and procedures have been established to ensure the highest quality of care. No shows and late cancellations prevent others patients from receiving much-needed care or treatments.*

Yes
No

Social Media Authorization: I grant full permission to Roscoe Village Animal Hospital to use photos/videos of my pet(s) on social media sites and for marketing materials (printed or electronic). This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of my pet's photograph and/or name.*

Yes
No

Phone

This field is for validation purposes and should be left unchanged.