Patient Form - Stoneridge Vet Clinic

Client Registration

Welcome to Stone Ridge Veterinary Clinic! Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your animal’s health.

To insure the best care possible, please take the time to either fill out this form completely or download the print friendly version a bring with you to your appointment.

Note: E-mail is an important form of communication concerning your pet. Please be sure to provide a current e-mail address and add [email protected] to your address book to avoid sending us to spam.

"*" indicates required fields

Patient Type*

Personal Information

Full Name*

First Last

Email*

Birth Date*

Home Phone*

Cell Phone*

Work Phone*

Personal Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation*

Employer*

Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security # Or Drivers License #*

Whom may we thank for referring you?*

Emergency Contact*

First Last

Emergency Contact Phone*

Animal Information

Animal Information*

Animal Name

Species

Breed

Color

Birth Date

Gender (M/F)

Sterilized (Y/N)

Reason for Animal's Visit*

Financial Agreement & Authorization

I hereby authorize the veterinarian to examine, prescribe for, and treat my animal(s). I assume responsibility for all charges incurred in the care of my animals. I also understand that payment is DUE AT THE TIME OF SERVICE. I have read and understand this policy and I accept responsibility for all fees. I understand that if I fail to pay as agreed, legal action will be taken against me. All charges not paid in full after 30 days will incur interest at the rate of 1.75% per month (21% per annum) or a repeat billing/service charge of $5.00, whichever is greater. I agree to pay any costs incurred in the collection process including but not limited to late charges, attorney’s fees, and a collection agency fee which would be $100.00 or ½ of the balance assigned, whichever is greater, with or without suit.

By checking this box you agree to the terms above*

I Agree

Digital Signature (type your full name)*

Frequently Asked Questions

Below are answers to questions that we are frequently asked by our patients and staff. If you are unable to find answers to your questions here, call us!

What are your office hours?

Our office hours are from 8:00am to 5:30pm Monday through Friday and Saturday 8:00am to 1:30pm. We take emergency visits during our office hours.

How do I make an appointment?

You can call us directly or request an appointment online by visiting our contact page.

If you have any other questions, please contact us

Contact Us

Monday	8:00am – 5:30pm
Tuesday	8:00am – 5:30pm
Wednesday	8:00am – 5:30pm
Thursday	8:00am – 5:30pm
Friday	8:00am – 5:30pm
Saturday	8:00am – 1:30pm
Sunday	Closed