Register your pet with Town and Country Veterinary Associates

Do you already have an appointment scheduled?*

Yes
No

If yes, what is the date of your appointment?*

Owner's Name

Name*

First Last

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

How did you find out about our practice?

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Where and when did you obtain your pet?

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

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

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Photo Release Policy

From time to time, we may ask if we could take a photo of your pet either for our social media sites, our website or our walls. But, of course, only if we have your permission to do so!

Do you grant Town and Country Veterinary Associates the right to take photographs of you and/or your pet, to copyright, use and publish for any lawful purpose, including publicity, illustration, advertising and social media / web content?*

Yes
No

Financial information

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, and 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 charges $30.00 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 will charge a $100 deposit fee to every new client per pet. New clients who cancel less than 24 hours prior to scheduled appointment or are late, will forfeit their deposit. Any client who misses a scheduled appointment will be required to pay a $100 fee per pet prior to making a new appointment. For clients with Pet Insurance, we are happy to help provide the necessary documentation to you to file a 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 agree to the above financial policies.

Today's Date

New Patient Registration