Name *

First

Last

Partner

First

Last

Email *

Primary Phone *

Secondary Phone

How would you like us to contact you? *

Phone
Email
Text

Providing your email address and cell phone number allows us to make sure your pet gets the preventative care that they need. Vaccination and other reminders are sent electronically via text and email. We also send health alerts and periodic bulletins. What is your preferred method of communication – please check ALL that apply.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Place of Employment *

Work Phone *

Driver License Number *

State Issued *

How did you find out about East/West Ridge Animal Hospital? *

If other, please specify *

Do we have your permission to use any photos of you and your pet for display in our clinic or online? *

Yes
No

I, the undersigned owner or agent of the owner, certify that I am 18 years of age or older, and do hereby authorize West Ridge Animal Hospital veterinarians and technicians to examine my pet and administer treatment as is considered necessary for my pet's condition. An estimate with care options can be discussed with me prior to any diagnostic treatments. In life threatening situations, stabilizing care may be instituted immediately upon arrival without an estimate. *

Clear Signature

We will gladly prepare a written estimate if you desire; please ask Doctor or receptionist. Unless prior arrangements have been made, ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept MasterCard, Visa, Discover, and American Express. We also accept Care Credit and Scratch Pay, and extended service fees may apply. There will be a $30.00 service charge for any check returned unpaid or credit card declined. Accounts after 30 days are subject to a 21% APR or $9.00 monthly billing fee, whichever is greater. By signing below, you authorize us to contact you by any or all of these methods, phone (home, work, cell), email, mail or text message and you accept these billing terms in the event of non-payment.

Date *

Preferred Location *

East Ridge Animal Hospital
West Ridge Animal Hospital

Patient Information

Pet's Name *

Age/Date of Birth *

Breed *

Color *

Species (dog, cat, etc.) *

Sex *

Male
Neutered Male
Female
Spayed Female

Allergies *

Long term medical problems:

Medications/Supplements currently on:

Do you have a second pet? *

Yes
No

Pet's Name *

Age/Date of Birth *

Breed *

Color *

Species (dog, cat, etc.) *

Sex *

Male
Neutered Male
Female
Spayed Female

Allergies *

Long term medical problems:

Medications/Supplements currently on:

Do you have a third pet? *

Yes
No

Pet's Name *

Age/Date of Birth *

Breed *

Color *

Species (dog, cat, etc.) *

Sex *

Male
Neutered Male
Female
Spayed Female

Allergies *

Long term medical problems:

Medications/Supplements currently on:

Do you have a fourth pet? *

Yes
No

Pet's Name *

Age/Date of Birth *

Breed *

Color *

Species (dog, cat, etc.) *

Sex *

Male
Neutered Male
Female
Spayed Female

Allergies *

Long term medical problems:

Medications/Supplements currently on:

Wellness Exam Questionnaire

Pet’s Name *

Your Name *

First

Last

Your pet’s current weight (in lbs) *

This is a change of how many lbs. from last year? *

What diet are you feeding? *

How much are you feeding? *

How many times daily do you feed your pet? *

How often does your pet visit the groomer? *

How often does your pet use a boarding kennel? *

How often does your pet go to daycare? *

What percentage of the time does your pet spend outdoors? *

Have you noticed any?

Does he/she have any trouble?

Getting Up
Climbing Stairs
Jumping/Running

Has there been any recent?

Vomiting
Diarrhea
Scooting

If so, how long ago and how often? *

Has there been any change in the frequency of amount of urination? *

Yes
No

Has there been an increase/decrease in water consumption? *

Increase
Decrease
Normal

Has there been a change in sleep patterns? *

Yes
No

Has your pet had any accidents in the house? *

Yes
No

Is there anything else that the doctor should know about?

Online Forms

New Client Form

New Client Form

Patient Information

Wellness Exam Questionnaire

Ready for a visit?

East Ridge Animal Hospital

West Ridge Animal Hospital

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