Rimforest Animal Hospital

Post Office Box 127/1299 Bearsprings Rd
Rimforest, CA 92378

(909)337-8589

www.rimforestanimalhospital.com

NEW PATIENT FORM

Click here to download and print this form. You may either email us the completed/scanned document, bring it with you to your appointment, or fill out the online form below.

 

New Patient Form

Owner's Name: (required)
First Name (required)
Last Name (required)
Owner's Date of Birth: (required) :
Post Office Box including City, State, Zip:

Street Address: (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
E-Mail Address: (required) :
Opt-in for medical records by email: (required)

Yes
No


Home Phone:
Phone TypePhone Number
Cell Phone: (required)
Phone TypePhone Number (required)
Employer: (required)

Employer Phone:

Significant Other's Name:

Significant Other's Date of Birth: :
Significant Other's Employer:

Significant Other's Employer Phone:

Pet's Name: (required)

Species: (required)

Sex: (required)

Male
Male Neutered
Female
Female Spayed


Breed: (required)

Color: (required)

Date of Birth: (required) :
Age: (required)

Previous Veterinarian:

Date of last visit: :
Reason for last visit:

Reason for today’s visit: (required)

Surgical history:

Allergies:

Vaccine reaction:

Date of last immunizations:
Rabies:

DA2PP:

Bordetella:

Influenza:

FVRCP (cats):

Leukemia (cats):

Leukemia test (cats):

List any medications your pet is taking:

Describe your pet’s diet and brand of food: (required)

Is your pet aggressive towards other animals or people? (required)

Is there anything else you would like us to know about your pet?

How did you hear about us? (required)

Yellow Pages
Online
Friend
Other



I understand that all fees are to be paid at the time my pet is released. I acknowledge that an estimate of fees can be provided at my request, and a deposit of 50% if my estimate exceeds $200 or if my pet is to be hospitalized. We accept cash, Visa, M/C, American Express, Discover and CareCredit
Yes, I understand
Today's Date: (required) :

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