• New Client Form

  • Client Information

  • Primary Owner

  • Format: (000) 000-0000.
  • Owner's DOB (for picking up pet medication)*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Preferred Contact Method*

  • Co-Owner

  • Format: (000) 000-0000.

  • Pet Information

  • Species*
  • Sex*

  • We cannot guarantee an allergy free environment

  • Information Release Authorization

  • * Please alert our care team if you would ever like to discontinue information release consent. If you decline to pre-authorize your consent to any of the following you will be contacted by phone for your approval prior to the release of your pet's record to any outside entity.*

  • I hereby authorize all representatives of Rum River Veterinary Clinic to release any medical history/information which may include vaccine history, behavior, past procedures, medications, etc. of my pet(s) to the following (please select):
  • Photo release

  • Clinic Policy Acknowledgement/Consent

  • *I, the undersigned, am the owner or agent for the owner of the animal(s) described and I have the full and exclusive authority to execute this consent. Please intial each item and sign and date the bottom of this form indicating your agreement.* 

  • I understand that all fees are due at the time services are rendered. This includes exams, diagnostics, treatments, medications, procedures, and any other services provided during your visit. The clinic accepts cash, all major credit cards, and CareCredit as payment options. The clinic does NOT accept checks as a form of payment. 

  • I understand that it is my responsibility to ensure payment is made in full. If another party is covering the cost of care, arrangements must be made in advance of the appointment. 

  • I understand that for surgical procedures, hospitalizations, or intensive treatments, a deposit may be required in advance. The remaining balance is due at the time of discharge or completion of services.

  • I acknowledge that I have read and understood Rum River Veterinary Clinic's cancellation policy and hereby agree to comply with the requirements listed as such. I have been provided with more information on the cancellation policy if and when requested. 

  • I acknowledge that I have read and understood Rum River Veterinary Clinic's Rabies vaccination policy and hereby agree to comply with any and all city mandated Rabies vaccination laws when applicable. I have been provided with more information on the Rabies vaccination policy if and when requested.

  • In compliance with MN statute 15.16 subd (12) Rum River Veterinary Clinic provides veterinary care within a veterinary-client-patient-relationship (VCPR). As such, I, the client, recognize this statute requires I present my pet for examination when needed, inform my veterinarian of the keeping and care of my pet, and follow the instructions of the veterinarian. I have been provided with more information on a VCPR if and when requested. 

    • I certify that I am 18 years of age or older.
    • I give permission to doctors, staff, or representatives or this hospital to examine, prescribe for, and treat my pets.
    • I release this hospital from any and all liabilities.

  • By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request.

  • Should be Empty: