New Client/Patient Information

New Client/Patient Information
Thank you for choosing Rhinebeck Animal Hospital to care for your pet! Please take a moment to review and complete our New Client/Patient Information form.

Client Information

First, please tell us a little about yourself!
Owner's Name *

First Name Last Name
Primary Phone Number *
Cell Phone Number
Work Phone Number
Email Address *
example@example.com
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add an alternate address and/or phone number for yourself? *

Yes No
Alternate Phone Number 1
Alternate Phone Number 2
Alternate Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add a spouse/significant other to your client account? *

Yes No

May we contact the previous clinic(s) for medical records/history?

Yes No
How did you learn about Rhinebeck Animal Hospital?

Internet Sign/Ad Yellow pages Personal Referral
Payment is due when professional services are rendered, or upon discharge of your pet from the Rhinebeck Animal Hospital. You are welcome to request an estimate for the cost of services. Payment may be made by cash, personal checks, and major credit cards (Visa, MasterCard, Discover, Amex), as well as CareCredit® and Apple Pay.
*

I have read and agree to the above information.
Signature *

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Client Information