Rainbow Veterinary Clinic

2636 Noble Rd
Cleveland Hts, OH 44121

(216)291-3931

www.rainbowvet.com

If you need immediate help, please click here to locate your nearest emergency clinic.

 

A deposit of $66.50 is required when making an appointment for new clients. 

We will also need any records that are available for your pet in order to make an appointment. 

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Phone Number (required)
Phone TypePhone Number (required)
Additional Phone
Phone TypePhone Number
E-Mail Address (required) :
Occupation

Employer

Preferred Method of Contact: (required) :
Preferred Method of Contact (other)

Alternate Contact
First Name
Last Name
Relationship

Alternate Contact Address
Street Address
City
,
State / Province
Zip / Postal Code
Alternate Contact Phone
Phone TypePhone Number
Alternate Contact Additional Phone
Phone TypePhone Number
Alternate Contact E-Mail :
Alternate contact occupation

Alternate contact employer

Pet #1 Information
Pet's Name (required)

Pet's Birthdate (approximate age if date unknown) (required)

Type of Pet (required) :
Breed:

Color/Markings: (required)

Sex: (required)

Male
Female


Neutered/Spayed (required)

Neutered
Spayed
Not spayed/neutered


Are your pets vaccines current? (required)

Yes
No


Pet #2 Information
Pets Name

Pet's Birthdate (approximate age if date unknown)

Type of Pet :
Breed:

Color/Markings

Sex:

Male
Female


Neutered/Spayed

Neutered
Spayed


Are you pets vaccines current?

Yes
No


Records
Do you have pets medical records? (required)

Yes
No


Medical records at another veterinary Practice? (required)

Yes
No


Name, Location and Phone Number of Former Veterinary Practice

May we request a transfer of records? (required)

Yes
No


Would you like us to call you for your appointment

Yes
No


Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

How did you hear about us?
Internet
Search engine or website

Friend
Friends Name

Ad
Where did see our ad?

Other
Please Specify

Please enter your name below to show that you understand that to make an appointment we require any records available & a deposit of $66.50 that will go towards your exam and is non-refundable unless you cancel or reschedule with at least 24 hours notice. (required)


Verify the reCAPTCHA: