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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Facebook
Internet Search
Personal Recommendation
Pet Health Information
Pet's Name
*
Species
*
Canine
Feline
Avian
Reptile
Exotic
Other
Breed
*
Color
*
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
*
Male
Female
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 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
*
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.
Home
About Us
Location & Hours
Our Veterinarians
Our Care Team
Office tour
Contact
Services
Preventative Health Care
Diagnostic/Laboratory
Dental Services
Surgical Services
Exotic Health Care
Additional Services
Medical Services
Pet Care
Patients
Forms
Payment Options
Pet Health
Pet Health Library
Pet Health Checker
Pet Insurance Info
News
New Clinic Updates
Fear Free
Pharmacy