Pet Registration Form

Premier VetCare Pet Registration Form
Cleint Information:

Please complete the following information to create your pet profiles for our practice. This will need to be submitted to us within 24 hours of your first or next visit, to confirm and hold any appointments that have been requested. If we do not have this information prior to the 24 hour window your appointment may be cancelled, and you will need to reschedule.

By completing and submitting this form prior to your visit we can speed up the check in process for you and your pet.
Primary Owner Full Name*

First NameLast Name
Primary Phone Number*
Format: (000) 000-0000.
Cell Number if not Primary Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
example@example.com

Third Pet Profile

Please provide us with your additional pet's information to create your pet's profile.
Pet's Name*
CanineFelineAvianOther
Pet's Breed*
MaleNeutered MaleFemaleSpayed FemaleUnknown
Pet's Coat Color*
Pet's Birth Date If Known

MonthDayYear
Date
Pet's Age*
What Date was your pet last vaccinated for Rabies?

MonthDayYear
Date
Brief Medical History or Prior Health Concerns.
Medical Upload

Cancelof
If you need to add more than Three Pets to your account you may do so by submitteding an additonal registration form.

Current or Past Veterinarian Information

To facilitate your pet's ongoing medical needs and continuation of care, we would like to know what practice may have been providing care for your pet(s) in the past.
Name of Current or Past Veterinarian Practice.
Phone number for Current or Past Veterinarian Practice.
Please enter a valid phone number.Format: (000) 000-0000.
E-mail for Current or Past Veterinarian Practice.
example@example.com
May we request records from your Current or Past Veterinary Practice?

If records are to be sent to our practice, please allow a minimum of 24-48 hours prior to your pets visit so that we can be sure to get those records before your appointment. Each veterinary hospital has their own policies in regards to how they process medical records requests. Some may require you to contact them to authorize the release of those records. Tennessee state law does require a written request from the owner of record prior to a practice releasing records to any other parties. To speed up your check in process, if we can facilitate request for records prior to your appointment time, that is preferred.

Your response below will be copied to an email we send to request a copy of your pet's medical records if you provide that consent. We will provide them your name, email, and phone number(s) so that practice may use that information to verify your request for records. They may reach out to you to confirm the request.

If you do not wish us to contact the practice on your behalf, please bring a copy of, at minimum, vaccination records to us at the time of your appointment or prior to it.
Yes, I give consent for you to request records and for them to release those records to you.No, please do not contact the practice for records, I will bring copies with me.No, please do not contact the practice for records. I will contact them to have them sent to you.There are no prior medical records available.Other

My Current Family VeterinarianOther
Electronic Signature
Type your Full name as you Electronic Signature
Full Name of Primary Account User
Should be Empty:

Premier VetCare Pet Registration Form

Pet Profile

Second Pet Profile

Third Pet Profile

Current or Past Veterinarian Information

May we request records from your Current or Past Veterinary Practice?

Electronic Signature