New Client Form in Olathe, KS | Ridgeview Animal Hospital

Registration

Date*

Owner*

First Name Last Name

Spouse

First Name Last Name

Address*

Street Address Address Line 2 City State Zipcode

Home Phone*

Work Phone*

Cell Phone

Spouse Cell

Driver's License Number*

E-mail Address*

Who can we thank for referring you?

Pet Health History

Name*

Age/Birthday*

Please choose one option:*

Dog
Cat

Breed*

Color

Please choose one:

Intact Male
Neutered Male
Intact Female
Spayed Female

Previous Veterinarian/Clinic and their telephone number*

Previous Vaccinations: (Please enter dates below)

Dog:

Rabies

Distemper

Parvo Virus

Corona Virus

Bordetella (Kennel Cough)

Lymes

CIV (Canine Influenza Virus)

Heartworm Test

Fecal

Cat:

Rabies

Distemper

Feline Leukemia Test

Feline Leukemia Vaccination

FIP (Feline Infectious Peritonitis)

CV (Calici Virus)

Heartworm Test

Fecal

Does your pet have any ongoing medical issues? If so, please explain:

Is your pet currently on heartworm prevention?*

Which heartworm prevention?*

Is your pet currently on flea or tick prevention?*

Which flea or tick product are you using?*

Pleae list any medications your pet is on:*

Please list any allergies your pet may have

Photo Release

I hereby assign and grant Ridgeview Animal Hospital and their representatives the right and permission to use and publish the photographs/film/video/electronic representations made of my pets by them and their representatives. I hereby release Ridgeview Animal Hospital from any and all liability from such use and publication. I hereby authorize the reproduction, copyright, exhibit, broadcast, electronic storage and/or distribution of said photographs/film/video/electronic representations without limitation at the discretion of Ridgeview Animal Hospital and I specifically waive any right to any compensation I may have for any of the foregoing.

Owner's Signature*

Authorization

I hereby authorize Ridgeview Animal Hospital to examine, prescribe for, or treat the pet described. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of the release and a deposit may be required in advance for surgical treatment.