New Client Form Pet Owner’s Name* First Last DOBCo-Owner/Spouse First Last Relationship with Co-Owner*We will need to have authorization from Co-Owner to be on the account for legal purposes.Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary PhoneCo-Owner PhoneEmployer’s Name and Phone NumberEmail Reason for VisitIs there anyone we can specifically thank for referring you to Riverside Animal Hospital?Are there any other Sources that have led you to us? Check all that Apply: Radio Location/ Drive-by Family/ Friends Internet Other Family/ Friend's NameOtherPayment Policy Payment is due at time of services. We will gladly prepare an estimate prior to performing treatments for your pet. We accept cash, check, Visa, MasterCard, Discover, American Express, and Care Credit. You must be 18 years of age or older to create an account or to authorize services. Untitled* I understand. BROKEN APPOINTMENT POLICYAt Riverside Animal Hospital, we strive to provide an exceptional client experience. Seeing and treating your pet in a timely, efficient manner is an important aspect of this experience. To do this, we reserve your appointment time as well as providing dedicated doctor and staff. To help accomplish this, we ask that you arrive and check in for your appointment on time.As a courtesy, we will provide you with appointment reminders through email, text, or phone call. However, it is your responsibility to keep track of and show up for your scheduled appointment.If for any reason you need to cancel or reschedule your appointment, we ask that you give our office at least 24-hour notice so that we can open your reserved time slot for another client.If an appointment is missed without appropriate notice, we will consider this a broken appointment and implement the following policy: 1st broken appointment: You will be advised and reminded of our Broken Appointment policy. 2nd broken appointment: A $40 broken appointment fee will be charged to your account. This broken appointment fee must be paid before or at the time you schedule your next appointment. You will also be required to make an exam fee deposit for future appointments. The exam fee deposit will be applied to that visit. If that appointment is missed, the exam fee deposit will be forfeited and another deposit will be needed for your next appointment.Untitled* I understand. Pet InformationNameBirth DateAgeSpecies Dog Cat Rabbit Ferret Other If otherBreedColorGender Male Female Spayed or Neutered? Yes No Not Sure Past Medical Conditions (Allergies, heart conditions, etc.)
