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New Client Information Form

Name: Santa Rosa Veterinary Hospital
Address: 2002 4th St, Santa Rosa, CA, 95404, United States
Telephone: 707-544-1313
Price range: $

Please fill out the following form before your scheduled appointment with us!

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New Client Information Form

Thank you for choosing Santa Rosa Veterinary Hospital. Please fill out the following form as thoroughly as possible so we can get to know you before your appointment with us. If you are in need of immediate assistance, please contact us at 707-544-1313.

Name *

First

Last

Main Phone *

Email *

Owner's Date of Birth *

(for narcotic rx)

I am over 18 years of age *

Preferred method of contact? *

Phone
Text
Email

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Employer (If self-employed, provide company name) *

Work Phone

Spouse/Partner Name

Spouse/Partner Phone

Additional Phone Number

(Cell/home Phone)

How did you hear about us? *

Location
Refer a Fur-iend
Other Personal Referral
Our Website
Other website
Other

Other Personal Referral Name

We love to share! May we post photos of your pet(s) to our Facebook page? *

Yes, please do!
No, thank you

LIABILITY RELEASE

Checkboxes *

I hereby authorize the doctors at Santa Rosa Veterinary Hospital (SRVH) to receive, prescribe for, treat, or operate upon my animals when presented by myself or my agent. I agree to pay all fees incurred in the treatment of my animals.

Checkboxes *

You are to use all reasonable precautions against injury, escape, or destruction of the animal(s), but you will not be held liable for any problems which might arise from the care, treatment, or safe keeping of the animal(s).

Checkboxes *

If the animal(s) is not picked up within fourteen (14) calendar days after the day the animal(s) was due to be picked up, said animal(s) will be considered abandoned. For a minimum of ten (10) days, efforts shall be made to find a new home for said animal(s) and if a home is not found, said animal(s) may be humanely destroyed. It is understood that your so doing does not relieve me from paying all costs of your services and the use of your hospital, including the cost of keeping.

Checkboxes *

I understand that SRVH will comply with California law regarding Rabies Reporting for dogs.

Checkboxes *

I authorize SRVH to send my records as requested to other veterinarians, specialty veterinarians, my insurance company, and governmental bodies. I understand that verbal authorization may also be required before records can be released.

Checkboxes *

I have read the foregoing and agree.

Client Signature *

Clear Signature

Date *

Ready for a visit?

We proudly serve the pets of Santa Rosa, Cotati, Rohnert Park, Sebastopol, Petaluma, and beyond. We look forward to seeing you and your pet—request an appointment today! And with our new app, you may request appointments 24/7, receive automatic reminders, save notes, photos, and much more.

Book Appointment Download App

Have a question?

Get in touch! Complete our online form, and a member of our team will be in touch with you shortly.

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Where to Find Us

2002 4th St
Santa Rosa, CA 95404

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Our Hours

Mon–Fri: 8am – 12pm & 1pm – 5:30pm
(Closed during lunch time)
Sat–Sun: Closed

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Get in Touch

707-544-1313
707-544-0417 (fax)
[email protected]

Name *

First

Last

Email *

Phone

How can we help you? *

Phone