New Client / Patient Registration

Owner's Name(Required)

First

Last

Spouse / Co Owner's Name

First

Last

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone(Required)

Spouse / Co owner's Phone

Owner's Date of Birth(Required)

Month

Day

Year

Spouse / Co Owner's Date of Birth

MM slash DD slash YYYY

Employer

Spouse / Co Owner's Employer

Referred by

Pet Health Information

Pet's Name(Required)

Age / DOB(Required)

Species(Required)

Breed(Required)

Color(Required)

Date of Birth

MM slash DD slash YYYY

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

Unknown

Is your pet currently on Heartworm Prevention?(Required)

Yes

If yes – Which Product are you using?

Please list your pets current medications:

Please describe your pets diet ( brand of food, etc):

Authorizations / Financial Policy

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. After hours emergency care is referred to either K-State University Teaching Hospital (785)532-5690 or Veterinary Emergency & Specialty Hospital of Wichita (316)262-5321.

We require payment in full at the time of service.

Payment Methods: Cash, Check, Visa, MasterCard, Discover, American Express or Care Credit (Some conditions apply and subject to credit approval)

In the event that there is an outstanding balance we charge 18% interest. 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.

I hereby certify that I am the owner of the above-described pet. Further, I herby request and authorize Town and Country Animal Hospital to release the requested medical information for my pet(Required)

Vaccine Information

Medical Information

I hereby give my permission to have my and/or my pets picture and/or video taken and published

Yes

By typing my full name in the space below I hereby certify that the foregoing information is true and correct, I agree to the foregoing terms of payment and I understand that this constitutes an electronic signature(Required)

Please fill out the Pre-visit questionnaire to the best of your ability so we can take into consideration both you & your pet’s preferences.

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Comments

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