REGISTRATION

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Would you like to receive e-mails from us? *

Yes
No

Cell Phone *

Other Phone

Would you like to receive texts from us? *

Yes
No

Employer

Work Phone

Your birthdate *

Driver's License

State

Co-Owner Name

First

Last

Cell Phone

Other Phone

How did you hear about us? *

Who may we thank?

PET HEALTH HISTORY

Pet's Name

Species

Cat
Dog
Other

If Other, please describe

Breed

Color

Birthdate

Sex

Vaccination History (date & type of vaccinations)

Previous Clinic

Phone

Upload Previous Medical Records

Click or drag a file to this area to upload.

Is your pet microchipped?

Yes
No

Microchip #:

Please list any allergies your pet has

Pet's current medications

Describe your pet's diet

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

If Other, please describe

Additional Information

AUTHORIZATION

I hereby authorize the veterinarian and staff to examine, prescribe for, and/or treat my animal(s). I assume full responsibility for all charges incurred for the care of my animal(s). I understand fees are due at time services are rendered and that a deposit may be required for treatment. I understand and agree in the event of default, to pay reasonable collection and/or attorney fees. Methods of payment are All Major Credit Cards, Debit Card, Care Credit ($200 minimum), & Scratch Pay. I authorize Tillema Veterinary Clinic to photograph/video my pet for medical records and social media purposes. I understand that I must arrive 10 minutes prior to my appointments and if I need to cancel, must do so with 24 hours notice to avoid restrictions. I certify that I am 18 years of age or older. *

I have read and understand.

Signature of Owner: *

Date: *

Welcome To
Tillema Veterinary Clinic

We know your pet’s health is important and we thank you for trusting us to care for them.

New Client Form

REGISTRATION

PET HEALTH HISTORY

AUTHORIZATION

Contact Us

Email Address

Call

Location

Hours

Have a Question?

Welcome To Tillema Veterinary Clinic

We know your pet’s health is important and we thank you for trusting us to care for them.

New Client Form

REGISTRATION

PET HEALTH HISTORY

AUTHORIZATION

Welcome To
Tillema Veterinary Clinic