NEW PATIENT & CLIENT INFORMATION

NEW PATIENT & CLIENT INFORMATION
Client information
Name *

First Name Last Name
Spouse's Name

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Spouse's Phone
Please enter a valid phone number.
Preferred Contact Number
Best Time to Reach you
Would you like to receive our educational newsletter?

yes no
Would you like email reminders instead of postcards?

yes no
Would you like email and/or text updates on your pet(s)

email or text email ONLY text ONLY Neither (Call me)
How did you hear about us
How did you first hear about us? *
If you were referred, by whom?
Where else have you heard about Tidewater Veterinary?

Sign / Neighborhood Internet Search Mt Pleasant Magazine Island Connection Moultrie News Other
Pet 1 Information
Name *
Species *

Canine Feline
Breed
Birthday or Age *
Sex

Male Female
Spayed / Neutered

yes no
Color
Please describe any chronic medical conditions, allergies, vaccine or medication reactions, immune medicateddiseases, and long-term medications that relate to your pet
Pet 1 Photo

Cancel of
Pet 1 Medical Records if available

Cancel of
Pet 2 Information
Name
Species

Canine Feline
Breed
Birthday or Age
Sex

Male Female
Spayed / Neutered

yes no
Color
Please describe any chronic medical conditions, allergies, vaccine or medication reactions, immune medicateddiseases, and long-term medications that relate to your pet
Pet 2 Photo

Cancel of
Pet 2 Medical Records if available

Cancel of
What are your goals for this veterinary visit?
What difficulties have you had with veterinary visits in the past?
Social Media
I give Tidewater Veterinary, LLC permission to post pictures of my pets on social media. *

I do I don't
Initial *
Date *

Month Day Year
Date
Authorized Persons for Pet’s Treatment Decisions (please list all that apply)
Spouse / Partner
Pet Sitter / Groomer
Children over 18 years old
Other
Pet Insurance
Company
Policy #
Hospital Financial Policy

Full payment is required at the time services are provided. I understand that upon my request the hospital staff will provide an estimate of any current and/or anticipated charges. By signing below, I am authorizing veterinary care be provided for the pet(s) presented by me or by agent(s). I am the legal owner/agents of this/these pet(s) and as owner/agent I understand that I am financially responsible for all services provided.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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NEW PATIENT & CLIENT INFORMATION

Client information

How did you hear about us

Pet 1 Information

Pet 2 Information

Social Media