New Client Registration – Town & Country Animal Hospital

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

Employer

Spouse / Co Owner's Employer

Email

Referred by

Pet Health Information

Pet's Name*

Species*

Breed*

Color*

Date of Birth

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.

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