Client Information

Welcome to our practice! Thank you for giving us the opportunity to care for your pet. To ensure you and your pet receive the best care possible, please fill out this form completely. Please print neatly and avoid the use of abbreviations. Please note that you are authorizing Rainbow Animal Hospital to contact you by any means listed below. Client Information: Name: Mailing Address: City: State: Zip Code: (Please list only the primary owner’s phone numbers here. Spouse/alternate phone # can be listed in the next section) Main Contact Number: Circle: Home Cell Work Text Message: Yes No Alternate Contact Number: Circle: Home Cell Work Text Message: Yes No Email Address: Social Security #: Employer: Occupation: Spouse/Sig Other Information (optional): Name: Social Security #: Main Contact Number: Circle: Home Cell Work Text Message: Yes No Alternate Contact Number: Circle: Home Cell Work Text Message: Yes No Employer: Occupation: Is there anyone you would like us to contact in the event of an emergency if the above parties are unreachable? Name: Phone: Please indicate how you learned about us: Hospital Sign/Building Location Yahoo Search Veterinarians.com/Local Vets.com Yellow Pages (Print Ad) Google Search Angie’s List.com Yelp Facebook Bing.com Other (Explain): Personal Recommendation (Who may we thank?): Please let us know if we have your permission to feature your pet’s photo on our Facebook page: circle one (yes/no) Name: ______Species: ______Breed: ______Sex (spayed or neutered): ______Coat Color: ______Birthdate/Age: ______Microchip #: ______Please list the dates of your pet’s most recent vaccinations against the following: Canine Distemper (DA2PL): ______Parvovirus: ______Bordatella: ______Rabies: ______Lyme Disease: ______Canine Influenza ______Feline Distemper/Upper Resp. (FVRCP): ______Rabies: ______Feline Leukemia Test/Vaccination: ______