New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
  • Owner's Name

  • Co-owner's Name & Contact #

  • Pet Information

  • Date Format: MM slash DD slash YYYY
  • We charge 18% interest on all outstanding account balances older than 30 days. Town and Country Animal Hospital may relinquish your balance owed to a collection agency. If the account is turned over to a collection agency there is a one-time collection fee of $35.00 that is added to the account prior to turn over. We also charge $30.00 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. If you have any questions please do not hesitate to ask. We are here to provide the best veterinary care available to your pet. By typing my full name in the space below I hereby certify that the foregoing information is trueand correct, I agree to the foregoing terms of payment and I understand that this constitutes an electronic signature