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New Patient Form
Welcome
About Us
Services
Holistic Services
People
Facility
Forms
New Patient Form
Nurturing happiness in animals
Online Pharmacy
Contact
New Patient Form
Thank you for choosing Town & Country Veterinary Clinic. Please fill out the form below and our Front Desk team will reach out with any next steps.
Date of Appointment
*
MM
DD
YYYY
Client Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Cell Phone
*
(###)
###
####
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Pet's Name
*
Species
*
Dog
Cat
Other
Sex of Pet
*
Male
Female
Unknown
Spayed / Neutered?
*
Yes
No
Unknown
Age
*
Unknown
Less than 1 year
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
Breed
Breed of pet. If unknown, please leave blank.
Color
Social Media
*
I give permission for Town & Country Veterinary Clinic to use my pet's picture and name on our social media sites, website, or any advertising materials.
Yes
No
TERMS & CONDITIONS
*
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED JOINTLY AND SEVERALLY GUARANTEE PAYMENT. I AGREE TO REIMBURSE TOWN & COUNTRY VETERINARY CLINIC THE FEES OF ANY COLLECTION AGENCY, WHICH MAY BE BASED ON A PERCENTAGE AT A MAXIMUM OF 32% OF THE DEBT, AND ALL COSTS AND EXPENSES INCLUDING ATTORNEY FEES IN SUCH COLLECTION EFFORTS. PAYMENT OF ALL FEES IS REQUIRED AS SERVICES ARE RENDERED. THERE WILL BE A $30.00 SERVICE CHARGE FOR ANY AND ALL RETURNED CHECKS. By typing your name below, you agree that you have read this form and are aware of the above payment policy. You agree that typing your name below is an acceptable form of signature.
Date
*
Thank you!
