New Patient Information

Type a question

Name

Spouse's Name

Address

City.

Zip Code

Email

example@example.com

Home Phone

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Spouse's Phone

Format: (000) 000-0000.

Best time to reach you

Unless otherwise stated below we will send you a text or an email regarding your pet's labwork results and to check on your pet after appointments and when they are sick.

Would you like email reminders instead of postcards?

How did you first hear about us?

Where else have you heard about Tidewater Veterinary? (Check all that apply)

Pet's Name

Is your pet a feline or canine?

What is the sex of your pet?

Breed

Birthday/Age

What is the sex of your pet?

Color

Please describe any chronic medical conditions, allergies, vaccine or medication reactions, immune medicated diseases, and long-term medications that relate to your pet.

Previous Veterinarian Information (Please include clinic name, phone number and the name of the owner of the pet whose records are under)

If you adopted your pet via a rescue or shelter, please email records to INFO@TIDEWATERVETERINARY.COM

2nd Pet's Name

What is your pet's sex?

Is your pet a feline or canine?

How old is your pet or when is your pet's birthday?

Is your pet spayed or neutered?

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).

Previous Veterinarian Information (Please include clinic name, phone number and the name of the owner of the pet whose records are under)

If you adopted your pet via a rescue or shelter, please email records to INFO@TIDEWATERVETERINARY.COM

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.

Signature

Date

Authorized Persons for Pet's Treatment Decisions (please list all that apply)

Spouse/Partner

Pet Sitter/Groomer

Children over 18 years old

Other

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

Date