New Client Form

Contact Information

* Full Name

Spouse / Significant Other

* Address

* City and Zipcode

* Email Address

* Phone Number

* Place of Employment

* Work Phone Number

* Alternate Contact

* Phone Number

Let's stay in touch! Please select your preferred method of contact:—Please choose an option—Phone CallText MessageEmail

We love to share! Does Roaring Brook Veterinary Hospital have permission to post your pet's picture on social media?—Please choose an option—YesNo, thank you

How did you become aware of Roaring Brook Veterinary Hospital

Personal Recommendation - Who may we thank?

Previous Veterinarian - Who may we thank?

Advertisement - Where did you see it?

Website or Social Media - Please specify where:

Roaring Brook KennelsHospital Sign

Payment Information

All fees are due at the time of service, or upon release of the patient. The undersigned agrees to pay finance charges of 1.5% per month (18% APR) plus billing fees, court costs and attorney fees on any unpaid balance.

< * Please select your preferred method of payment: (We accept Visa, Mastercard, Discover, American Express and Care Credit—Please choose an option—CashDebit / Credit CardCheck

* Signature

* Date