TVAC New Patient Form

Tennessee Valley Animal Clinic, P.C.

1582 Hwy 72 E Tuscumbia AL 35674 256-386-9800
WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Name*

First NameLast Name
MI
SPOUSE
CELL PHONE #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL ADDRESS
example@example.com
YOUR EMPLOYER
SPOUSE EMPLOYER
WORK PHONE
SPOUSE WORK PHONE
ADDITIONAL PHONE
SPOUSE CELL PHONE
HOW DID YOU LEARN ABOUT OUR CLINIC?
PET HEALTH HISTORY
NAME OF PET*
TYPE OF PET*

DOGCATOther
SEX*

MALE INTACTMALE NEUTEREDFEMALE INTACTFEMALE SPAYED
BREED*
COLOR*
BIRTHDATE OR AGE*
VACCINE HISTORY (IF NOT AT THIS CLINIC)
REASON FOR VISIT*
PET MEDICAL HISTORY: For example please list current diet, any allergies to medications, serious medical problems previously or currently being treated, or other important information we should know about your pet.
AUTHORIZATION
We sometimes will post cute, funny, and interesting picture of patients we see at Tennessee Valley Animal Clinic on our social media pages. Will you allow us to post images of your pet on social media.

Yes, I DO give the staff of Tennessee Valley Animal Clinic permission to post images of my pet on social media.No, I DO NOT give the staff of Tennessee Valley Animal Clinic permission to post images of my pet on social media.
*

Full payment is required at the time services are provided. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. By signing below, I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided.
SIGNATURE*
DATE OF SIGNATURE*

MonthDayYear
Date
METHOD OF PAYMENT

CARE CREDITCASHDISCOVERMASTERCARDVISASCRATCHPAY
Should be Empty:

Tennessee Valley Animal Clinic, P.C.

PET HEALTH HISTORY

AUTHORIZATION