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Call/Text: 605-399-2665

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New Client Registration Form

Owner's Information
Name*
First Last
Address*
Street Address Address Line 2 City ZIP Code
Contact Information
Day-Time Phone*
Drivers License #*
Evening Phone
Mobile Phone
Email*
Confirm Email*
Co-Owner's (Spouse) Information
Name
First Last
Phone
Are you or your spouse active or retired military?*
- Active
- Retired
- No
Emergency Contact Phone number IF different from Co-Owner:
Referral Information
How did you find out about our practice?
- Clinic Location
- Personal Referral
- Internet Search / Website
- Yellow Pages
- Clinic Sign
- Newspaper / Print Media
- Other
If other, please specify
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information #1
Pet's Name
Species*
Dog Species*
Species*
If other species not listed above
Breed (If known)
Color
Date of Birth (if known)
MM slash DD slash YYYY
Special Identification (tatoo, microchip, etc.)
Sex
Intact Male Sex
Sex
Pet Information #2
Pet's Name
Species*
Dog Species*
Species*
If other species not listed above
Breed (If known)
Color
Date of Birth (if known)
MM slash DD slash YYYY
Special Identification (tatoo, microchip, etc.)
Sex
Intact Male Sex
Sex
Pet Medical History
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Last date of vaccines (if known)
Date of last vaccine (if known)
MM slash DD slash YYYY
Is your pet on any medication or supplement?
- Yes
- No
If yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
- Yes
- No
If yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If yes, please comment on the conditions(s) and indicate if they are current or past conditions
Please use the following box to provide us with any other relevant information about your pet

39186

Contact Us

1727 E Anamosa St., Suite 100
Rapid City, SD 57703

Phone: 605-399-2665
Fax: 605-341-0222

Clinic Hours

Open Mon-Thu: 7:30am-5:00pm
Closed Fri, Sat, Sun

Request Appointment

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Updates

Did you know you can shop online with us? Place your orders online and get regular automatic shipments of preventatives, chronic medications, and even specialty diets delivered directly to your home!

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