Rainbow Veterinary Clinic

2636 Noble Rd
Cleveland Hts, OH 44121

(216)291-3931

www.rainbowvet.com

New Client Form

You can either print the pdf and mail/email/fax it to us, or you can fill out the form below.

Please Print and fill out this form.

Name *(required)*

First Name (required)	Last Name (required)

Phone Number (required)
Phone Type	Phone Number (required)

Additional Phone
Phone Type	Phone Number

E-Mail Address (required) :

Preferred Method of Contact: (required)

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary Practice?

Yes
No

Name, Location and Phone Number of Former Veterinary Practice

May we request a transfer of records?

Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

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HOURS