New Client Form in Muscatine, IA | Riverside Animal Hospital

Pet Owner’s Name*

First Last

DOB

Co-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 Country

Primary Phone

Co-Owner Phone

Employer’s Name and Phone Number

Email

Reason for Visit

Is 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:

Family/ Friend's Name

Other

Payment 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 POLICY

At 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 Information

Name

Birth Date

Age

Species

If other

Breed

Color

Gender

Male
Female

Spayed or Neutered?

Yes
No
Not Sure

Past Medical Conditions (Allergies, heart conditions, etc.)

New Client Form

BROKEN APPOINTMENT POLICY

Pet Information

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