Please fill out our New Patient Form using one of the options below if your pet is a new patient at Rancho Regional Veterinary Hospital.

Option 1

Complete Online

Complete and submit the online form below.

Option 2

Download Form

Print our Patient Questionnaire and bring it with you to your appointment.

Patient Questionnaire

Option 3

Complete on Arrival

If you prefer, fill out the form when you get to our hospital.

New Patient Form

Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Employer *

Occupation *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Rancho Regional Veterinary Hospital to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Rancho Regional Veterinary Hospital to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Rancho Regional Veterinary Hospital.

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Patients

Patients
New Patient Form
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Pet Care Tips

Routine Wellness Exams for Your Pet

Animals need regular physical exams to identify health problems before they become serious.

Learn More

We’re Welcoming New Patients!

We're always happy to welcome new patients to our animal hospital. Get in touch today!

Vaccinations & Parasite Prevention

Preventive vaccinations and parasite control are the cornerstone of your pet's health.

Learn More

Emergencies

Happy Tails

I’ve been going to Rancho Regional for years for my animals and today they really helped me out. I had a vaccination appointment for my dog and my 4-year-old daughter wasn’t feeling well and had a fever. Rancho Regional helped expedite my dog's vet appointment so I could get home to my daughter. As well as accommodating my dog because she is pet reactive. They took me straight to a room to ensure the safety of my dog and others. I really appreciated their staff today and how helpful they were.
- Crystal L.

New Patients Welcome

Rancho Regional Veterinary Hospital is accepting new patients! Our experienced vets are passionate about the health of Rancho Cucamonga companion animals. Get in touch today to book your pet's first appointment.