Client Information

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Patient Information

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a third pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

FINANCIAL POLICY

Thank you for choosing Town and Country Veterinary Associates for your pet’s healthcare. We strive to provide the highest level of veterinary care available to your pet. We realize that costs are a factor in caring for your pet. This page will outline our financial policy, which includes several different payment options. Please be aware that payment in full is expected at the time of services.

Payment Options: We accept

-Cash

-MasterCard

-Visa

-American Express

-Discover

-CareCredit

-A CareCredit account offers convenient monthly payments, with no minimum amount. Additionally, the amount may be interest free for up to six months.

Deposits

For some treatment or hospitalization, a deposit may be required. The amount of the deposit can range from 25% - 50% of the total estimated bill and is due at the time services are begun.

Additional Information

Town and Country Veterinary Associates charge a $30 fee for all returned checks. We do not resubmit returned checks. If your check is returned for insufficient funds, payment must immediately be made by cash or credit card. No exceptions. Town and Country Veterinary Associates charge a $100.00 deposit fee to every client per new pet. Clients who cancel less than 24 hours prior to the scheduled appointment or are late, will forfeit their deposit. Any client who misses a scheduled appointment or cancels within 24 hours will be required to pay a $100 fee per pet prior to making a new appointment. No exceptions. For clients with Pet Insurance, we are happy to provide the necessary documentation to you to file your claim. If you have more than two claim forms that need supporting paperwork, you must arrange with office staff to have the paperwork prepared and allow us up to 5 business days to gather the information. Additional time may be necessary depending on the amount of documentation needed. By signing below, you acknowledge your understanding of our policy and agree to its terms. This form must be signed and returned prior to the first appointment.

I have read and accept the financial policy.

Welcome to Town & Country Veterinary Associates

New Client Form

Client Information

Patient Information

Request an Appointment with Us

Request an Appointment with Us

Location

Contact Information

Hours

Have a question?