New Patient

New Patient
After filling out this form in full, a representative from the clinic will contact you.

Please be sure to attach prior medical records below.
Owner Information*

First NameLast Name
Spouse / Other

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cellphone Number*
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Email*
example@example.com
Is there anyone else that you authorize to bring in your pet and/or treat your pet in case of an emergency?

First NameLast Name
Are you currently a client with us, or have you been in the past?*

YesNo

Patient Information*
Name
Species*
Sex
Breed and Color*
Date of Birth*

MonthDayYear
Date
Does your pet have a microchip?*

YesNo
Does your pet have any history of medical problems? If yes, please explain:
Is your pet currently on any medications (including heartworm/flea prevention, any supplements, or any over-the counter product)? If so, please list below:
Have you noticed any behavioral changes in your pet over the last few months (i.e. not playing as much as before, drinking/urinating more, hiding, etc.)? If so, please describe:
Does your pet have previous medical records, adoption papers, or forms from a vaccine clinic? Your appointment will not be booked until records are received.*

Yes (It is required that you attach all records below or we will be unable to schedule an exam)No (If not you may have to restart vaccine series)
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Deposit for First Appointment

Due to the high volume of new clients not showing up for their first appointment, we now require a deposit for the first appointment.
- The deposit of $81.00 will be applied to your first exam.
- If you cancel with a minimum of 24 hours notice the money will be refunded to you.
- If you do not show up for your scheduled appointment, the $79.00 deposit is forfeited.
- Should you fail to show up for your appointment and forfeit your deposit and wish to make another appointment it will require another deposit to hold the slot.
- Payment can be made over the phone or in the office. (Cash or Charge)
Please know that we have instituted this policy to make sure that people who schedule an appointment show up, or so they remember to cancel the appointment should they not be able to make it. This allows us more appointment time to accommodate patients.
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Financial Policy

Thank you for choosing Riverside Veterinary Clinic. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Riverside requires payment in full at the end of your pet's examination and/or at the time of discharge.

Payment Options:

You can choose from:

- Cash, Check, Debit, Visa®, MasterCard®, American Express®, Discover®

- Convenient Monthly Payment Plans¹ from CareCredit®

o Allow you to begin treatment today and pay overtime

o Available for any treatment amount over $100

o Can be used repeatedly - for your entire family - without having to reapply¹

o 5% Administration fee for use of this payment plan

For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

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By signing below, you acknowledge that Riverside does not offer payment plans and agree to provide payment when services are rendered.
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Riverside Veterinary Clinic Vaccine Policy
**IMPORTANT: PLEASE READ**

In order to keep all of our patients, clients, and staff safe, it is required that your pet be up-to-date on its rabies vaccination. Having your pet vaccinated for rabies is a Massachusetts state law. In order to handle your pet, proof of current rabies vaccination must be presented to our staff. If your pet does not have a current rabies vaccine, we require that your pet be vaccinated at the time of its appointment. The only exception to this will be if one of our doctors deems that it is not medically safe to vaccinate your pet. If you decline to have your pet vaccinated against rabies, we will respectfully understand but will not be able to serve your veterinary needs. If you have concerns regarding this, please call to speak with us prior to your appointment.

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Section 145B: Vaccination against rabies; certificate; tag; proof of vaccination; exemption; penalty

Section 145B. (a) Each owner or keeper of a dog, cat or ferret that is 6 months of age or older shall cause such dog, cat or ferret to be vaccinated against rabies by a licensed veterinarian using a licensed vaccine according to the manufacturer's directions and shall cause such dog, cat or ferret to be revaccinated at intervals recommended by the manufacturer. Unvaccinated dogs, cats or ferrets acquired or moved into the commonwealth shall be vaccinated within 30 days after the acquisition or arrival of such animal into the commonwealth or upon reaching the age of 6 months, whichever last occurs. It shall be the duty of each veterinarian, at the time of vaccinating a dog, cat or ferret, to complete a certificate of rabies vaccination which shall include, but not be limited to, the following information: the owner's name and address; a description of the animal, including breed, sex, age, name and distinctive markings; the date of vaccination; the rabies vaccination tag number; the type of rabies vaccine used; the route of vaccination; the expiration date of the vaccine; and the vaccine lot number.

(b) The veterinarian shall issue a tag with each certificate of vaccination. The tag shall be secured by the owner or keeper of the dog, cat or ferret to a collar or harness made of suitable material to be worn by the dog, cat or ferret; provided, however, that the owner of a cat or ferret may choose not to affix the tag, but shall have the tag available for inspection by authorized persons. In the event that a tag is lost, the owner or keeper of the animal shall, upon presentation of the original vaccination certificate, be issued a new tag.

(c) In order for a dog, cat or ferret to be accepted at an animal hospital, veterinarian's office or boarding facility, an owner or keeper of such animal shall show proof of current vaccination

against rabies; provided, however, that if an animal has not been so vaccinated or such owner or keeper fails to show proof of vaccination, the animal shall be vaccinated against rabies prior to being discharged if the animal's medical condition permits.

(d) A licensing authority may grant an exemption from this section for a dog, cat or ferret that:

(i) the local board of health has declared exempt from the rabies vaccination requirement upon presentation of a veterinarian's certificate stating that because of an infirmity, other physical condition or regimen of therapy, such inoculation is considered inadvisable for a specified period of time for such reasons; (ii) is in transit; or (iii) was brought into the commonwealth temporarily for the sole purpose of display in a show or for exhibition.

(e) This section shall not apply to a dog, cat or ferret housed in a research institution.

By signing below, you agree to the States Rabies Policy:
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New Patient

After filling out this form in full, a representative from the clinic will contact you.

Deposit for First Appointment

Financial Policy

_____________________________________________Riverside Veterinary Clinic Vaccine Policy**IMPORTANT: PLEASE READ**

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Riverside Veterinary Clinic Vaccine Policy
IMPORTANT: PLEASE READ