Ridge Lake New Client & Patient Form V2

Welcome to Ridge Lake Animal Hospital
Thank you for giving us the opportunity to care for your pet! Please help us meet your pet's needs better by taking a moment to share some important information with us.
Owner Name: *

First Name Last Name
Co-Owner / Spouse Name:

First Name Last Name
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number:

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Alternate or Spouse's Phone Number:

Area Code Phone Number
Please select your preferred phone number you'd like us to contact: *

Cell Phone Home Phone Alternate or Spouse's Phone
Email Address: *
example@example.com
Driver's License #:
(Only required if writing a check)
Are you in the Military, a First Responder, or a Senior Citizen? *

Pet(s) Information: *

Pet's Name

DOB/Age

Sex

Spayed/Neutered

Breed

Color

Pet #1

Pet #2

Pet #3

MEDICAL HISTORY
Has your pet ever been to another veterinarian? We would like to contact your previous veterinarian to obtain their medical records so we can provide the best care possible. *

Yes No
If you have selected "yes", please tell us the previous hospital's name, city/state, and phone number:
Previous Hospital's Name:
City / State:
Phone Number

Area Code Phone Number
MEDIA RELEASE
Here at Ridge Lake Animal Hospital, we love to consider your pet as a part of our family. We occasionally like to share pictures of your pet on Facebook. May we include pictures of your pet on these forms of social media?

Yes No
Please sign your signature below: *

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Ridge Lake Animal Hospital business and medical staffing hours are: Monday: 7:00am to 7:00pm, Tuesday: 7:00am to 7:00pm, Wednesday: 7:00am to 7:00pm, Thursday: 7:00am to 7:00pm, Friday: 7:00am to 7:00pm, Saturday: 7:00am to 1:00pm, and Sunday: Closed. I have read and understand this form and am aware of the above stated staffing hours of Ridge Lake Animal Hospital. Please sign your signature below: *

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Date: *

Month Day Year
Please enter today's date
Should be Empty:

Welcome to Ridge Lake Animal Hospital