New Patient Intake Form * If your pet has a medical emergency, phone your nearest emergency pet hospital. New Client Intake Form How Did You Hear About us? * GoogleFacebookFriendOne of Our DoctorsGiant EagleOther How Did You Hear About us? Whom may we thank for referring you? Pet Owner Name (Primary Contact) * Co-Owner Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone Type * Cell Landline Primary Phone Number * Alternate Phone Number Co-Owner Primary Phone Type Cell Landline Co-Owner Primary Phone Number Co-Owner Alternate Phone Number Emergency Contact Name * Emergency Contact Phone Number * Email * Text & Email Notifications We can notify you of upcoming appointments, medication refills and annual check-ups. Text & Email Notifications * Yes! That would be very helpful to receive reminders. No thanks. I like things as they are. Patient Information Have more than one pet? Click the "Add" button to provide information on your whole four-legged family. Pet Number 1 Pet's Name * Species * DogCat Date of Birth - Approximate Sex * MaleMale NeuteredFemaleFemale Spayed Breed * If mixed breed, what does your pet most resemble? Color/Markings * Please list any chronic conditions (e.g. diabetes, autoimmune disease etc.) Medications/Supplements Please include the name, dose, and frequency of the drug/supplement (e.g. Carprofen 25mg every 12 hours) Prior Surgeries or Illness Please select all that apply DHPP (Distemper) Rabies Lepto Lyme Bordatella Heartworm Test Please select all that apply Feline Distemper Rabies Leukemia FIV/Leukemia Test Heartworm Test Is your pet current on rabies vaccination * Yes No Do you have verification of rabies vaccination for your pet? * Yes No plus1 Add minus1 Remove Photography Consent We adore our patients, and love to share photos and stories about the wonderful pets we see every day. May we feature your pet too? I hereby grant to River Valley Veterinary Hospital, its representatives and employees, the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that River Valley Veterinary Hospital may use such photographs of me and/or my pet with or without my name for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. Authorization: * I allow River Valley Veterinary Hospital to use images of my pet(s) and myself. I allow River Valley Veterinary Hospital to use images of my pet(s) ONLY. I do not wish for images of myself OR my pets to be shared. Authorization For Treatment Please Read & Agree To This Authorization For Treatment I hereby authorize the staff of River Valley Veterinary Hospital to render any treatment that is deemed necessary to my pet(s) health while in custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that professional fees are to be paid at the time services are rendered and a deposit is required on all pets admitted to the hospital. I Have Read And Agree To The Authorization For Treatment * Yes reCAPTCHA Submit
