New Client Registration – Town & Country Animal Hospital

Client / Patient Registration

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

Client Information
Owner's Name*
First Last
Spouse / Co Owner's Name
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Spouse / Co owner's Phone
Owner's Date of Birth*
MM
DD
YYYY
Spouse / Co Owner's Date of Birth
Date Format: MM slash DD slash YYYY
Employer
Spouse / Co Owner's Employer
Email
Referred by
Pet Health Information
Pet's Name*
Species*
Breed*
Color*
Date of Birth
Date Format: MM slash DD slash YYYY
Sex*
Spayed / Neutered*
- Yes
- No
- unknown
Is your pet currently on Heartworm Prevention?*
- Yes
- No
If yes - Which Product are you using?
Is your pet currently on Flea Prevention?*
- Yes
- No
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 end of your pet’s examination and/or at the time of the discharge. Payment Options: You can choose from: Cash, Check, Visa, MasterCard, Discover, AmericanExpress or Care Credit. 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.
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*
- Vaccine Information
- Medical Information
I hereby give my permission to have my and/or my pets picture and/or video taken and published*
- Yes
- No
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*
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

https://tcvets.com/fear-free-questionnaire/

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 12:00pm
Sunday	Closed

Client / Patient Registration

Client Information

Pet Health Information

Authorizations / Financial Policy

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Hours of Operation