Cell Phone #
Street Address Line 2
State / Province
Postal / Zip Code
Secondary Name on Account:
Spouse, partner, family member
Preferred Communication Type
How did you learn about our clinic?
Name of Pet
Spayed or Neutered?
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
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 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.
DATE OF SIGNATURE
Should be Empty: