Client and Pet Registration

    Welcome to our clinic and thank you for choosing Ravenwood Veterinary Clinic for your pet’s care. Please complete the following information about you and your pet(s) accurately. Your pet’s medical records are confidential and just as important as yours. Thank you!

    When is your appointment scheduled?

    Date:

    Time:

    Please call your previous clinic and have your pet’s records sent to us via fax, (386) 756-8970, or email, frontdesk@ravenwoodvet.net.

    About You…

    Client Name:

    Street Address:

    Apt./Unit#:

    City:

    State:

    Zip:

    E-Mail Address:

    Home Phone:

    Cell Phone:

    Spouse Name:

    Spouse Phone:

    Driver License #:

    Employer Name:

    Work Phone:

    Preferred Method of Contact:
    HomeCellWork

    Preferred Method of Contact for Reminders:
    CallEmailTextMail

    How were you referred to our office?
    WebsiteClientOther

    About Your Pet(s):

    Pet Name 1:

    Sex:
    MaleMale NeuteredFemaleFemale Spayed

    Age and/or Date of Birth:

    Species:
    CatDogOther

    Breed:

    Color:

    Date of Last Vaccines:

    Location of Last Vaccines:

    ---

    Pet Name 2:

    Sex:
    N/AMaleMale NeuteredFemaleFemale Spayed

    Age and/or Date of Birth:

    Species:
    N/ACatDogOther

    Breed:

    Color:

    Date of Last Vaccines:

    Location of Last Vaccines:

    ---

    Pet Name 3:

    Sex:
    N/AMaleMale NeuteredFemaleFemale Spayed

    Age and/or Date of Birth:

    Species:
    N/ACatDogOther

    Breed:

    Color:

    Date of Last Vaccines:

    Location of Last Vaccines:

    There will be a $25.00 Fee for Appointments Not Cancelled within 24 hours and No-Show Appointments.

    *Client Initials:

    Payment Policy…

    Our Office Does Not Offer Billing. Payment is Due on the Day of Service. We will gladly prepare a written estimate if you desire. Please ask our doctor during your appointment. Occasionally, a deposit may be required for certain procedures. We accept the following forms of payment: Cash, Personal Check, Credit/Debit., including Care Credit, Visa, MasterCard, Discover and American Express.

    *Please note that when writing a personal check, a copy of a valid driver’s license will be needed for processing.

    There is a $27.00 fee for a returned check in addition to the fees your bank may charge.

    *Client Initials:

    Inpatient Information

    To help prevent the spread of infectious disease, it is recommended that all hospitalized patients are current on all vaccines. Please provide proof that your pet is currently up to date.

    *Client Initials:

    Treatment/Payment Authorization

    I understand every effort will be made to achieve a successful outcome and provisions will be made for safe in-hospital care and handling. I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time of services are completed, unless prior arrangements have been made. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, interest, attorney fees, court costs, and collection agency fees.

    I hereby authorize Ravenwood Veterinary Clinic to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible and authorize treatment necessary should any reactions occur.

    *Signature of Owner or Authorized Caretaker:

    Date:

    Social Media Release

    I grant permission for Ravenwood Veterinary Clinic to use photo’s for the purpose of social media post (Facebook, Twitter, YouTube, & other sites).

    *Signature of Owner or Authorized Caretaker: