New Client Registration Online Form - CORNERSTONE ANIMAL CLINIC

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We look forward to your first visit with us. Help us get to know you and your pet(s)
and fill out the form below prior to your first visit. Thank you.

New Client Registration

* Indicates required field

Owner Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Preferred Phone Number *

Select Phone Type *

Spouse or Alternate Contact Name *

First

Last

Spouse or Alternate Contact Email *

Spouse or Alternate Contact Phone *

Emergency Contact (Name and Phone) *

Pet Information and Health History

PET #1

Pet's Name *

Date of Birth *

Sex *

Species *

If you chose 'Other' species please indicate here *

Breed *

Color/Markings *

Vaccination History (date and type of last vaccinations) *

PET #2

Pet's Name *

Date of Birth *

Sex *

Species *

If you chose 'Other' species please indicate here *

Breed *

Color/Markings *

Vaccination History (date and type of last vaccinations) *

PET #3

Pet Name *

Date of Birth *

Sex *

Species *

If you chose 'Other' for species please indicate here *

Breed *

Color/Markings *

Please provide us with contact information to your previous Veterinarian so we can obtain any past medical records.

Hospital Name, Name of Veterinarian, Phone, Address, etc *

If your pet(s) are not feeling well and you are scheduled for an Appointment, please fill out the information below.

Which pet are you referring to? (Pet Name) *

Please check any symptoms that you have noticed about your pet (check all that apply) *

Behavior problems Bleeding gums Breathing problems Coughing Diarrhea Eye Bulging or Bloodshot Gagging Lack of appetite Limping Loss of balance Scooting Scratching Seems depressed Shaking head Thirst and/or Urination increased Vomiting Weakness Other symptoms

If you chose 'Other symptoms' please indicate here: *

Pet's Current Medications, if any *

What type of food does your pet eat? *

Authorization

AUTHORIZATION: I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. If also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. Please Acknowledge this authorization with your full name below: *

Date *

Submit

Hours of Operation

Monday 7:30-5:30pm
Tuesday 7:30-5:30pm
Wednesday 7:30-5:30pm
Thursday 7:30-5:30pm
Friday 7:30-5:30pm
Saturday Closed
Sunday Closed

Cornerstone Animal Clinic

36 E Stumer Road, Suite 126
Rapid City, SD 57701
(605) 719-7355
Email: [email protected]

Visit Us

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Home
About
Services
Contact
Resources
- New Client Registration Form
- Petly Pages
Online Pharmacy