Quarry Ridge Animal Hospital

30 Old Quarry Road
Ridgefield, CT 06877

(203)438-8878

www.qrah.com

New Client Check In

By providing this information prior to your arrival, we can greatly expedite your check in process. We look forward to meeting you. You may submit this by e-mail, copy and fax it to 203-438-4266, or copy and bring with you at the time of the appointment. We are currently reviewing e-mails & faxes at 8:00 a.m. & 1:00 p.m. Mon- Fri.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
E-Mail Address :
Daytime Phone (required)
Phone TypePhone Number (required)
Home Phone (required)
Phone TypePhone Number (required)
Pet's Name (required)

Type of Pet :
Are your pets vaccines current?
Would you like us to call you to make an appointment?
Reason for this Appointment Request? (required)

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Quarry Ridge Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Quarry Ridge Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



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