Intake Form - RiNoVet

Client Name

First

Last

Spouse/ SecondaryName

First

Last

Phone

Secondary Phone

Home Address

Address, City, State, Zip

Email

How did you hear about us?

Pet Name

you Secondary Banfield

Age/ DOB

Select

Feline
Canine

Breed & Coloring

Multiple Choice

Spayed Female
Intact Female
Neutered Male
Intact Male

Primary Veterinary Clinic (specify location for Banfield or Thrive):

In the event that your pet has a cardiac or respiratory arrest, do you authorize RiNoVet Animal Emergency Care to perform CPR? You acknowledge that there are costs associated with CPR and you are responsible for all costs incurred.

CPR
DNR

Confirm Above

CPR
DNR

Typed Digital Signature

By signing (typing name) below, you certify that you are over the age of 18 and are the owner (or authorized agent) of the above-described patient. You authorize RiNoVet Animal Emergency Care personnel to treat your pet. You understand that you are not guaranteed a successful outcome and you shall not hold the hospital (or its affiliates, employees, agents or contractors) liable for procedures performed and recovery of your pet. You understand that if your pet must be hospitalized, a deposit of the low end of your estimate must be made prior to treatments. Full payment for services rendered will be required prior to the discharge of your pet. You understand you are responsible for all costs incurred and if it becomes necessary to pursue legal action to recover the balance due, you agree to pay all collection, attorney and court fees associated in addition to a service fee.