Anthony J. Smith, DVM
Hercules, CA  94547
(510) 381-3389
© Copyright 2018 Rainbow Bridge Vet Services
New Patient Registration Form
If you would like to arrange an appointment online, please go to our Schedule Appointment Page.
Otherwise, if you have already reserved a time with us, or aren't sure about timing, please complete
and submit the form below and we will contact you shortly. Feel free to contact us via phone or email
if you have any questions or difficulty completing the form.
Please be sure that you are directed
to a
nd complete the Deposit after hitting the submit button (otherwise check for possible
errors in the form).
If you don't arrive there, we will not receive your information.
Your Information
(* Required Field)
Alternate Phone
*Primary Phone
*Your name (First & Last)
*Street Address
Is there anything we should know about finding your place or parking?
Names of others who may be present? (Family, friends, other pets)
Your Pet's Information
*Pet's Weight
*Pet's Sex
*Pet's Name
*Pet's Breed
Pet's Age
*Pet's Main Ailment
Pet's Color
Pet's Regular Veterinary Hospital(s)
Is there anything we should know about your pet's temperament or behavior? (e.g. afraid of men, hates
shots, fearful, aggressive, etc.)
Appointment Information
What days and/or times would work best for an appointment? (If already scheduled, please indicate date/time)
What type of aftercare would you like for your pet? (See Pricing Page for Charges)
How did you hear about us?
Questions, comments, or feedback: