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New Client Form

A deposit of $100.00 is required for all new clients and is due when the initial appointment is scheduled.  The deposit funds will be applied toward your pet’s first appointment.  The deposit is non-refundable for “no shows” or if the appointment is canceled without giving 24 hours’ advanced notice. Thank you.

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.

"*" indicates required fields

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

Co-Owner Information

Co-Owner's Name

Your Pet's Information

Pet's Name:*
MM slash DD slash YYYY

Second Pet (if applicable)

MM slash DD slash YYYY

Referral Information

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.

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.*
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.*
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.*