New Client & Patient Registration Form

Owner's Name

Name*

First Last

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

Pet Information

Pet's Name*

Species*

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Is your pet up to date on their vaccines?*

Yes
No

Date of last vaccines (if known)

MM

DD

YYYY

What vaccines were given at this time

Is your pet on any medication or supplement?*

Yes
No

If Yes, please list the medication or supplement

Does your pet have allergies or drug reactions?*

Yes
No

If Yes, please list the allergies and reactions

What is your pet’s reason for visiting us today?*

Please check any symptoms that you have noticed about your pet:

I hereby authorized the veterinarians & staff to examine, prescribe for, and/or treat the above-described pet.*

I assume responsibility for all charges incurred in the care of this animal. I also understand that any and all charges will be paid for at the time when services are rendered and that a deposit may be required for hospitalization, treatment and/or surgery.*

I understand that in order to protect my privacy, information regarding client and or patient information can only be released to the owners named above, and a medical record release form will need to be completed and signed by the above named owner(s).*

TILLMAN’S CORNER VETERINARY HOSPITAL DOES NOT OFFER BILLING. ALL PAYMENTS ARE DUE IN FULL AT THE TIME WHEN SERVICES ARE RENDERED. PLEASE INFORM EITHER A VETERINARIAN OR TECHNICIAN IF YOU REQUIRE AN ESTIMATE BEFORE SERVICES ARE PERFORMED.*

PAYMENT FORMS ACCEPTED: CARE CREDIT, CASH, VISA, MASTERCARD, DISCOVER AND AMERICAN EXPRESS*

Name of Owner*

First Last

Date*

Owner's Name

Co-owner's Name & Contact #

Pet Information

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