Name
First Name
Last Name
Cell Phone #
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Name on Account:
Spouse, partner, family member
Preferred Communication Type
Text
Email
Phone Call
How did you learn about our clinic?
PET INFORMATION
Name of Pet
Species
Dog
Cat
Other
Gender
Male
Female
Unknown
Spayed or Neutered?
Yes
No
Not Sure
Breed
Color
Birthdate or Age
Does your pet have any long term medical problems?
If your pet is on any medications please list them:
Please include over-the-counter medications and supplements.
What is your reason for visiting us?
Previous veterinary office so we can request records:
Name and phone number
Additional Pets to Register? List Here:
Name, species, breed, gender, age
AUTHORIZATION
Please check whether or not we have permission to use your pet's picture on our website and/or social media. We love sharing adorable pictures of pets!
Yes, that is OK
No thank you
I understand that being more than 10 minutes late for my appointment may result in additional fees or being rescheduled.
I understand
I hereby authorize Pleasant Ridge Pet Hospital and Cat Care Clinic to examine, prescribe for, and treat my pet(s). I assume responsibility for all charges incurred in the care for and treatment of my pet(s). I also understand that these charges will be paid upon receipt of service and take responsibility for collections charges should they incur.
*
I agree
SIGNATURE
*
DATE OF SIGNATURE
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: