New Client Registration Form - Tipton Ridge Veterinary Medical Center

New Client Form

Primary Owner's Full Name

Address

Address 2

City

State

ZIP

Phone

Additional Owner's Full Name

Additional Owner Phone

Relationship to Primary Owner

Emergency Contact Name

Emergency Contact Phone

Pet Name

Species

Breed

Color

Sex

Age or Date of Birth

Is your pet microchipped?

Describe any known allergies or vaccine reactions

Describe any medical conditions or medications

Previous vet name and phone # (If no previous vet, enter "N/A")

Additional Pet Name

Species

Breed

Color

Sex

Age or Date of Birth

Is your pet microchipped?

Describe any known allergies or vaccine reactions

Describe any medical conditions or medications

Previous vet name and phone # (If no previous vet, enter "N/A")

How did you hear about us?

Referred by (if applicable)

I acknowledge that the hospital may photograph or record pets while on the premises for use in marketing materials, including but not limited to social media, the hospital website, and digital advertising. I understand that my pet may appear in such media, and I can opt out at any time by notifying the hospital.

I understand and agree

I understand that payment is due in full at the time services and products are provided. I acknowledge that acceptable forms of payment include cash, credit/debit cards, and CareCredit for clients who have been approved. I understand that treatment plans and estimates are available upon request and may change based on my pet’s medical needs.

I understand and agree

Signature