Ridgemoor Animal Hospital - New Client Registration

To ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us.

Your Name

Spouse/Partner Name

Street Address

City, State, Zip

Home Phone

Work Phone

Mobile Phone

Fax Number

E-mail

What is the best way to contact you?

Home Phone Cell Phone E-mail Postal Mail

Occupation/Emplyoyer

Emergency Contact:

Emergency Contact Name
(if other than spouse)

Emergency Contact's Phone

Is this person authorized to make decisions about your pet’s health? Yes No

How did you hear about us?

Were you referred to us by one of our clients?

# of Pets in Your Household

Pet Information:

Pet Name

Species

Dog Cat Other

If Other Species

Breed

Color

Sex

Male Female

Date of Birth

Neutered/Spayed?

Yes No

Microchipped?

Yes No

Pet's weight

Pet Health History:

Name of the hospital that we can request your pet’s records from

Please describe your pet's daily diet

Does your pet have any medical conditionls or allergies?

Is your pet currently on heartworm prevention?

Yes No
Brand?
(e.g. heartgard, revolution, sentinel)

Is your pet currently on flea prevention?

Yes No
Brand?
(e.g. frontline, revolution, comfortis)

Any other pets in your household?

Dogs Cats Birds
Other:

Disclaimer
(read-only)

I affirm that the information given herein is true and correct to the best of my knowledge. Payments are due at time
services are rendered. We accept all major credit cards, debit, checks, and cash.

When you are finished, click submit to send the form information