New Client and Patient Form

5900 Jack Finney Blvd.

Greenville, TX 75402

(903) 454-6222

www.turtlecreekvmc.com

New Client and Patient Form
Type a question*

New ClientExisting Client
Does your pet already have an appointment scheduled at our hospital? If yes, please enter date/time of your appointment. If no, please call to schedule after submitting form.
Pet Owner's Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
Driver's License Number
State
Email - Your email address will be used as a primary venue of contact for your pet's health reminders. We DO NOT send out paper reminder cards.
example@example.com
Mobile Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Which number should be listed as your primary form of contact?
Please list any additional authorized individuals you would like included on your account. Please be advised - these individuals will have access to account information and possess the ability to authorize medical treatments and charges.

Add Another Pet
Pet Information
Pet's Name
Species
Pet's Age or DOB
Pet's Gender
Breed
What hospital can we contact to obtain your pet's previous medical records?
To maintain compliance with state law, all pets must have a record of current Rabies immunization to receive services at our hospital. If your pet is not current, a Rabies immunization will be administered at your expense. Please initial below to verify this requirement has been understood and accepted.
Does your pet have any medical conditions, such as allergies, drug or vaccine reactions, heart conditions, etc?
Please list all medications your pet currently takes, including supplements:
Is your pet current on heartworm preventative? If yes, what brand do you use?
Is your pet microchipped? If yes, what is their microchip number?
Does your pet have pet insurance? If yes, what company do you use?
Please indicate your pet's typical diet:

Dry KibbleCanned FoodRaw DietHomemade Diet
What brand of food does your pet typically eat?
Does your pet eat table food or scraps?

YesNo

Financial Policy
Thank you for choosing us as your veterinary health care provider. We are committed to your pet's treatment being successful and as cost effective for you as possible. The following is a statement of our Financial Policy. We ask that you read and sign below.
- Full payment is due a the time service is rendered. We accept cash, debit, VISA, MasterCard, Discover, Care Credit, and Scratchpay. WE DO NOT ACCEPT CHECKS. If there are any questions regarding fees or charges, please inform a member of our team before any services are performed.
- Before any pet is admitted to the hospital, a deposit will be required before services are rendered with the BALANCE DUE IN FULL UPON RELEASE.
Signature*

Clear
Printed Name:*
Date*

MonthDayYear
Date
Should be Empty:

Pet Information