Client and Pet Registration

Welcome to our clinic and thank you for choosing Ravenwood Veterinary Clinic for your pet’s care. Please complete the following information about you and your pet(s) accurately. Your pet’s medical records are confidential and just as important as yours. Thank you

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About You...
Client Name *
Client Name
Spouse's Name
Spouse's Name
Address
Address
Home Phone Number *
Home Phone Number
Please provide us with a Contact Phone Number where you can be reached while your pet is with us today:
Cell Phone Number
Cell Phone Number
Spouse's Phone
Spouse's Phone
Work Phone
Work Phone
Preferred Method of Contact
Please check one.
Preferred Method of Contact for Reminders
How were you referred to our office?
If referred by a current client, please let us know who to thank!
If referred by a current client, please let us know who to thank!
About Your Pet(s)
Pet #1
Please choose one.
Date of Last Vaccines
Date of Last Vaccines
Do You Have Additional Pet's?
Pet #2
Please choose one.
Date of Last Vaccines
Date of Last Vaccines
Pet #3
Date of Last Vaccines
Date of Last Vaccines
There will be a $25.00 Fee for Appointments Not Cancelled within 24 hours and No-Show Appointments
Please type your initials below to confirm.
By typing your initials here, you agree to the above statement.
Payment Policy
Our Office Does Not Offer Billing. Payment is Due on the Day of Service. We will gladly prepare a written estimate, if your desire. Please ask our doctor during your appointment. Occasionally, a deposit may be required for certain procedures. We accept the following forms of payment: Cash, Personal Check, Credit/Debit., including Care Credit, Visa, MasterCard, Discover, & American Express. *Please note that when writing a personal check, a copy of a valid driver’s license will be needed for processing. There is a $27.00 fee for a returned check in addition to the fees your bank may charge.
By typing your initials here, you agree to the above statement.
Inpatient Information
To help prevent the spread of infectious disease, it is recommended that all hospitalized patients are current on all vaccines. Please provide proof that your pet is currently up to date.
By typing your initials here, you agree to the above statement.
Social Media Release
I grant permission for Ravenwood Veterinary Clinic to use photo’s for the purpose of social media post (Facebook, Twitter, Youtube, & other sites)
Treatment/Payment Authorization
I understand every effort will be made to achieve a successful outcome and provisions will be made for safe in-hospital care and handling. I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time of services are completed, unless prior arrangements have been made. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, interest, attorney fees, court costs, and collection agency fees. I hereby authorize Ravenwood Veterinary Clinic to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible and authorize treatment necessary should any reactions occur.
By typing your name below you confirm that you are the sole owner of your pet(s), and that we may perform the following duties according to your submitted form. By submitting this form you agree to all of the above submitted, including form disclosures.
Today's Date *
Today's Date

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