TCAH New Client Registration Form

TCAH New Client Registration Form
Owner

First Name Last Name
Secondary Owner

First Name Last Name
Mailing Address

Address

Address Line 2

City State / Province

Postal / Zip Code
Physical Address (if different from mailing address)
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email
example@example.com
Driver's License State & Number
Example- TX 12345645
Driver's License Expiration Date
Pet's name (please list each pet separately)
Species
Breed
Color
Age or DOB
Gender
Pet's name (please list each pet separately)
Species
Breed
Color
Age or DOB
Gender
Pet's name (please list each pet separately)
Species
Breed
Color
Age or DOB
Gender
Please list any additional pets:
Authorization: I hereby Authorize the veterinarian to examine, prescribe for or treat any animals presented for services. I assume responsibility for all charges incurred during their care. I also understand that these charges will be paid for in full at the time of services or before the time of release of the patient(s).

{owner}
Signature

Clear
Today's Date

Month Day Year
Date
I give permission for my pet medical records and vaccination history to be released. (Example- when requested by other veterinary and/or animal care facilities you use, such as veterinary specialists, veterinary practices, groomers, or boarding facilities.)

Yes No
Should be Empty: