New Client Form We are glad to have the opportunity to care for your pet. Our mission is to provide compassionate care by our dedicated experts. To ensure exceptional service, please fill out this form completely. Please email your pet's medical records or fax to 1-800-549-3114. Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you give permission to RVAH to communicate with you by email?*YesNoDo you give permission to RVAH to communicate with you by email and text message for appointment reminders?*YesNoPrimary Phone:*HomeMobileWorkAlternative Phone:HomeMobileWorkEmail:* Co-Owner InformationCo-Owner's Name First Last Co-Owner Phone:HomeMobileWorkCo-Owner Email: Previous Veterinary HospitalDo you have pet insurance?*YesNoName of Pet Insurance CompanyPolicy NumberYour Pet's InformationPet's Name:* Pet's Date of Birth:* Date Format: MM slash DD slash YYYY Breed:*Color:*Gender:*MaleFemaleIs your pet neutered/spayed?*YesNoIs your pet microchipped?*YesNoPet's Microchip NumberDoes 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?*YesNoSecond Pet (if applicable)2nd Pet's Name2nd Pet's Date of Birth: Date Format: MM slash DD slash YYYY 2nd Pet's Breed:2nd Pet's Color:2nd Pet's Gender:MaleFemaleIs your 2nd pet neutered/spayed?YesNoIs your 2nd pet microchipped?YesNo2nd Pet's Microchip NumberDoes 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?YesNoReferral InformationHow 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 PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
