First Name
Last Name
Street Address
City
State/Province
Zip/Postal Code
Email Address
Cellular Phone
Home Phone
Work Phone
Preferred primary phone contact
Secondary Name on Account
Secondary Contact Phone
Do you live within the city limits?
Who may we thank for referring you?
Or how did you find out about us?
Pet's Name
Age: Years, Months or Birthdate
Sex
Neutered or Spayed?
Breed
Color
Are your pet's vaccine's current?
Name of Former Veterinary Practice
May we request a copy of your pet's records?
Would you like us to call you to schedule an appointment?
Please list your top 3 preferred dates and times for an appointment
Date & Time (1)
Date
Time
Date & Time (2)
Date
Time
Date & Time (3)
Date
Time
If already scheduled, when is your appointment?
Reasons or conditions that prompted your visit?
Special requests or conditions?
Please list any additional pets here
Method of Payment:
Please Read: I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Rock Bridge Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Rock Bridge Animal Hospital's collection agency, and will incur a $35 collection fee for which I am liable, in addition to monthly finance charges.
A $50 booking fee will be collected to hold my appointment spot for me. This fee is NON-refundable if I cancel my appointment with less than 24 hours notice. This fee will be applied towards my invoice if my appointment is kept as scheduled. I can cancel my appointment by calling 573-443-4501.
I have read the above statements and
Please type "Yes" in the box so we know you are not a computer
How would you describe your pet's reaction to going to the veterinary hospital?
How does your pet travel in the car? Does your pets show signs of car sickness, such as drooling or vomiting? Does your pet seem anxious or uncomfortable?
Are there any procedures or activities in the veterinary hospital that your pet is not comfortable with such as noises, getting on the scale or exam table, or certain parts of the exam?
What are your pets favorite treats? (Please bring some to your next visit to our hospital)
Has your pet ever been prescribed medications to help with a visit to the veterinary hospital? If so, please list below.
Is there anything else you would like us to know?
Please upload your pet's records if you have them (Max file size 2 MB):
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