Client Information

Name(Required)

First Last

Client D.O.B.(Required)

(Required to dispense controlled substances)

Cell(Required)

Home(Required)

Driver's License(Required)

Email(Required)

(Your email address will not be shared with any other party)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please let us know how you heard about us

Patient Information

Pet Info(Required)

Name

Species

Sex

Spayed/Neautered

Age

Breed

Color

I authorize Roseville Animal Hospital to use photos of my pet for social media and advertising.(Required)

(initial)

I authorize Roseville Animal Hospital to share my pet’s medical records if they are requested by other hospitals or facilities.(Required)

(initial)

I understand that I must pay for services rendered at the time of discharge.(Required)

(initial)

I understand that the state of California requires my pet to have a current Rabies vaccine; Roseville Animal Hospital reserves the right to require one be given before treatment is administered.(Required)

(initial)

I understand that Roseville Animal Hospital is not a 24 hour facility and does not provide overnight care.(Required)

(initial)

Signature(Required)

Date(Required)

New Client Form

Client Information

Patient Information