New Client/Pet Form – Town And Country Veterinary Clinic

Owner's Information

Name*

First Last

D.L. #

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Business Phone

Cell Phone*

Other Phone

Email*

Who else is responsible for your pet?

Phone

Previous vet:

Phone

City/State:

How would you like to be reminded of future recommended preventive health care services?*

How did you hear about our hospital? (Who can we thank?) List all that apply.

Individual
Social Media (Facebook, Yelp)
Website
Internet Search (Google)
Clinic Sign
Other

Thank you for the opportunity to care for your pet.

Please provide individual's name so we can thank them:

Please specify other so we can thank them:

Consent

I do grant my permission for Town and Country Veterinary Clinic, LLC to use any of my pet’s photos on the clinic website, social media, advertisement, etc.

New Pet's Information

Name*

Sex*

M
F

Species*

Dog
Cat

Breed:

Microchip #:

Date of Birth or Approx. age?

Spayed/ Neutered?

Color/ Markings:

What type of food do you feed your pet, how much and how often?

List significant events and procedures in your pet’s life. (Include any surgeries)

What medications/supplements do you currently give your pet? (Include last time given)

Does your pet have any known allergies or reactions to vaccines?

Is your pet on Heartworm Prevention?

Yes
No

Type:

Last given:

Is your pet on flea prevention?

Yes
No

Type:

Last given:

Consent*

I understand every effort will be made to achieve a successful outcome and to provide safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat, or perform surgery upon the pet(s) listed and any additional pets I present. Furthermore, I agree to pay for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I understand that at my request a written estimate will be provided. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee of $20.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent. I understand that veterinary service is provided during nighttime hour as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet(s) within 5 days of the discharge and do not notify you within that time period, you may assume that the pet is abandoned and are hereby authorized to rehome/dispose of the pet as you deem best and/or necessary.

New Client and Pet Form

Owner's Information

New Pet's Information

Education, compassion, and complete care for you and your companion.

Contact

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Address

Hours