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New Client Information Form
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.
Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in to providing optimal care for your pet(s). The required sections have a blue * asterisk.
Step 1 of 2
50%
Owner/Agent:
Name
*
First
Last
Mobile Phone
*
Work Phone
*
Can we text you?
*
Yes
No
DOB
*
MM
DD
YYYY
Your Driver's License #
*
Your Employer
*
Spouse
Spouse Name
First
Last
Mobile Phone
Work Phone
DOB
MM
DD
YYYY
Spouse Driver's License #
Spouse Employer
Your Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Enter Email
Confirm Email
Home Number
Emergency Name
Emergency Phone
How did you hear about us?
*
Social Media
Style Magazine
Location
Rocklin Chamber of Commerce
Placer SPCA
Fieldhaven
Kitten Central
Google/Bing
Yelp
Referral
Other
If Referral, whom may we thank?
If Other, please explain:
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Breed (if known)
*
Color
*
Date of Birth or Age (if known)
*
Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Does your pet have allergies or drug reactions?
*
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
*
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Do you have a 2nd pet?
*
Yes
No
2nd Pet's Name
Species
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Breed (if known)
Color
Date of Birth or Age (if known)
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Does your pet have allergies or drug reactions?
Yes
No
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please list the allergies and reactions
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Do you have a 3rd pet?
Yes
No
3rd Pet's Name
Species
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Breed (if known)
Color
Date of Birth or Age (if known)
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Does your pet have allergies or drug reactions?
Yes
No
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please list the allergies and reactions
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
I, the undersigned, do hereby consent and agree that Rocklin Road Animal Hospital, its employees, or agents have the right to take photo, videotape, or digital recordings of my above-listed pet(s) and release all rights to exhibit this work in print and electronic form publicly or privately. I also understand that Rocklin Road Animal Hospital is not responsible for any expense or liability incurred as a result of my, or my pet(s) participation in any photos and/or recordings.
*
Accept
Decline
I hereby authorize the staff at Rocklin Road Animal Hospital to examine, prescribe for and treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this/these animal(s). I also understand that all charges will be paid at the time of release of my pet and that a deposit may be required before treatment.
*
Accept
Signature of Owner/Agent
*
First
Last
Date
Date Format: MM slash DD slash YYYY
New Clients
What to Expect
New Client Information Form
Make an Appointment
About Us
Location & Hours
Team
Community Work
Rx and Food Form
Services
Surgical Services
Diagnostics
Dermatology
Cardiology
Orthopedics
Opthalmology
Oncology
Pet Dental Care
Dental Wellness Package
Pet Teeth Cleaning Under Anesthesia – Pros and Cons
End of Life Care
Boarding
Boarding Reservation Request Form
Boarding Release Form
Grooming
House Calls
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
Pet Insurance Info
News
Pet Resources
Spay or Neuter
Puppy & Kitten Care
Payment Options
Petly Health Records
Pet Insurance
Emergencies
Pharmacy
