Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Method of Contact:

Driver’s License Number:

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

If so, what is the I.D. number of the microchip?

Typical Food (i.e. brand, variety, wet, dry, etc.):

Amount:

Which fits your pet’s living arrangement?

Indoor
Outdoor
Both

If you answered “Both”, about how many hours is your pet outside and indoor daily?

Specific Medical History:

Does your pet have any known allergies or reactions to any medication or food?

Yes
No

If you answered “Yes” above, please elaborate here:

Is your pet up-to-date on vaccinations?

Yes
No

Is your pet on heartworm prevention?

Yes
No

Is your pet on flea and/or tick preventative?

Yes
No

Are you coming from a different doctor or hospital?

Yes
No

If “Yes”, what is the name of doctor/hospital:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Professional fees are to be paid at the time services are rendered. We do not bill. It is our policy to provide a written estimate of fees whenever hospitalization or emergency care is needed. A late charge is applied to all accounts unpaid after 30 days. Late charges are computed by a periodic rate of 1.5% per month, which has an annual rate of 18.0%. *

I have read and accept the financial policy.

We have made changes to our after-hours operation

New Clients

New Client Form

Request An Appointment

Using CareCredit for Veterinary Financing

Rittman Clinic & Lodge Address

Clinic Hours

Lodge Hours

Have a Question?