New Patient Information

New Patient Information
Type a question

Mr.Mrs.Ms.MissDr.
Name
Spouse's Name
Address
City.
Zip Code
Email
example@example.com
Home Phone
Cell Phone
Work Phone
Spouse's Phone
Best time to reach you
Would you like email and/or text message updates on your pet(s)?

EmailTextEmail or textNeither, I prefer a phone call
Would you like email reminders instead of postcards?

YesNo
Would you like to recieve our educational e-newsletter?

YesNo
How did you first hear about us?
Where else have you heard about Tidewater Veterinary? (Check all that apply)

Drive by/Walk byGoogle/Internet SearchReferral by another client
Pet's Name
Is your pet a feline or canine?

FelineCanine
What is the sex of your pet?

MaleFemale
Breed
Birthday/Age
What is the sex of your pet?

SpayedNeuteredIntact
Color
Please describe any chronic medical conditions, allergies, vaccine or medication reactions, immune medicated diseases, and long-term medications that relate to your pet.
2nd Pet's Name
What is your pet's sex?

MaleFemale
Is your pet a feline or canine?

FelineCanine
How old is your pet or when is your pet's birthday?
Is your pet spayed or neutered?

SpayedNeuteredIntact
Breed
Color
Please describe any chronic medical conditions, allergies, vaccine or medication reactions, immune medicated diseases and long term medication that is related to your pet(s).
What are your goals for this veterinary visit?
What difficulties have you had with veterinary visits in the past?
I do / do not give Tidewater Veterinary dba CU Tiger Veterinary permission to post pictures of my pets on social media.

YesNo
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Date
Authorized Persons for Pet's Treatment Decisions (please list all that apply)
Spouse/Partner
Pet Sitter/Groomer
Children over 18 years old
Other
Do you have pet insurance? Please list the company and policy number below.
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.
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