New Client Information Form

Phone

This field is for validation purposes and should be left unchanged.

Client Information

Pet Assure Number

Owner's Name(Required)

First Last

Spouse's Name

First Last

Address(Required)

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Cell Phone(Required)

Additional Phone

Email(Required)

Where did you hear about Rocky Hill Animal Hospital?

Friend

Sign

Internet Search

Facebook

Hilltop Dog Hotel

Radio Ad

Other

Payment is required at the time services are rendered

Pet Information

List Pet Information of all pets within household(Required)

Name

Species

Breed

Color

DOB

Sex

Fixed

 

Add Remove

Date of Last Vaccinations(Required)

Where?

(We must have a copy of the previous vaccination history from a licensed Veterinarian) Each client is responsible for providing vaccination records either by fax or bringing a hard copy to RHAH upon pet drop off for boarding, grooming, etc.

If records are not received vaccines will be given.

BORDETELLA VACCINE IS REQUIRED AT RHAH EVERY 6 MONTHS.

Currently on Medication(Required)

Yes

No

Specify

The undersigned affirms the information provided above is correct and agrees to all conditions as stated in the above paragraph.

Signature of Owner or Agent:(Required)

Date(Required)

MM slash DD slash YYYY

******This form is for new clients who have contacted us to set up an appointment time by phone, Online Portal, or our Request an appointment page. Please visit our Appointment Request page, or call for any assistance at 865-691-8826. We appreciate your help. Thanks!********

Did you know that with our Online Portal app you can have 24/7 access to your pet’s records and information? You can also send appointment requests, please visit our online store by clicking here. Download today in the apple or android store and add us as your pet’s provider.  Sign up