Welcome Form

Name: Roxbury Animal Clinic
Address: 156 Baker Rd, Roxbury, CT, 06783, United States
Telephone: 860-354-8612
Price range: $

Appointment

Welcome Form

Personal Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Alternate Phone

Email *

Birth Date: *

*Date of birth is required for any controlled drugs prescribed by our doctors

Driver License #:

Date Issued

Spouse/Partner Name

First

Last

Emergency Contact Information

Name *

First

Last

Cell Phone *

Alternate Phone

Relationship *

Do we have permission to use your cell phone for text purposes? *

Method of Contact and Payment

Preferred method of contact: *

Email
Text
Cell Phone

How will you be paying for service today: *

Cash
Check
Credit Card

Would you like us to hold a credit card on file?

Veterinary Client Patient Relationship

I hereby consent to a veterinary client relationship (VCPR), mandated by the state of Connecticut, which is required for all animals to be examined by a licensed veterinarian at Roxbury Animal Hospital every 12 months. I understand that this relationship is necessary to diagnose, prescribe, and medically treat each patient. I assume all financial responsibility incurred at Roxbury Animal Hospital. This relationship can be terminated at any time by either party. *