Primary Account Holder

Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name

Cell Phone *

Use for reminders or Financial Records

Use for reminders
Financial Records

Name

Email *

Use for reminders or Financial Records

Use for reminders
Financial Records

Name

Landline

Use for reminders or Financial Records

Use for reminders
Financial Records

Children (Name and Age)

Secondary Account Holder

Name

Relationship

Name

Cell Phone

Use for reminders or Financial Records

Use for reminders
Financial Records

Name

Email

Use for reminders or Financial Records

Use for reminders
Financial Records

Pets

Pet's Name *

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a second pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a third pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a fourth pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a fifth pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a sixth pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a seventh pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a eighth pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a nineth pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Do you have a tenth pet? *

Yes
No

Pet's Name

Age/Date of Birth *

Sex *

Male/Neutered
Intact Male
Female/Spayed
Intact Female

Species (dog, cat, etc.) *

Breed *

Color *

Insurance Carrier

Add a Photo of Your Pet (Optional)

Click or drag files to this area to upload. You can upload up to 8 files.

We love getting to know our furry patients even before we meet them! You have the option to upload a photo of your pet, which we will include in their personal chart. This helps our team recognize your pet upon arrival and adds a personal touch to their profile. Feel free to upload your favorite snapshot. This is entirely optional, but it's a great way for us to start connecting with your pet right away!

Photos and Social Media!

Do you give us permission to take photos of you and your pet during your appointment and use them for educational purposes on our social media platforms such as Facebook, Instagram, and our Website? *

YES, I would love that!
No

Please list individuals authorized to approve veterinary care and charges for your pets(s):

This is most commonly a family member or caretaker; You do not need to list the primary account holder or secondary account holder listed above. *

I authorize these individual(s) to approve treatment/charges on my behalf without a veterinarian contacting me prior
I do not authorize anyone to approve treatment on my pets, aside from the account holder(s) listed above.

Name

Phone

Relationship

Name

Phone

Relationship

May we contact your previous veterinarian for copies of your pets(s) records? *

Yes
No

Clinic Name

Doctor History: Please check any that apply:

Dr. Caelli Edmonds at Cinder Rock Veterinary Clinic
Dr. Jessica Puccetti at Cinder Rock Veterinary Clinic
Dr. Jessica Puccetti at East Bend Animal Hospital
Client at Black Diamond Equine Veterinary Clinic

Doctor Approach to Veterinary Care (all are options at RVC): *

Traditional Western Medicine
Integrative Medicine
Holistic Medicine
Unsure

Referral - Whom may we thank for sending you our way? *

Would you like us to grant you access to the online portal, so you may book appointments online? *

Yes
No

Payment is due in full at the time of each service

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described animal(s). I assume responsibility for all charges incurred for the care of my animal(s). I also understand that these charges will be paid at the time of service whether I am present or not, and agree to place a credit card on file if needed. Please ask for an estimate if one has not been provided to you. We accept cash, checks, and credit cards. Payments with cash at the time of service will be given a 2% discount. *

I Agree and Understand

By signing my name below, I agree to terms of service and consent to veterinary care for my animal(s). *

Clear Signature

Owner’s Signature

Date *

New Client Form

New Client Form

Primary Account Holder

Secondary Account Holder

Pets

Photos and Social Media!

Please list individuals authorized to approve veterinary care and charges for your pets(s):

Payment is due in full at the time of each service

Ready for a visit?

Questions?

Location

Contact Information

Hours