New Companion Animal Hospital Client Registration Form

2930 Tazewell Pike
Knoxville, TN 37918
(865)689-2719
Fax: (865)689-7496
Text: (865)240-2274
Email: companionAH@companimal.com

Owner Full Name:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone:

Area CodePhone Number

Cell Phone #1:

Area CodePhone Number

Work Phone:

Area CodePhone Number

Spouse Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Emergency Contact:

Name

First NameLast Name

Phone Number

Area CodePhone Number

How did you learn of our clinic?

Facebook/InternetDrive byRecommendation

Who recommended us?

Pet Information

Pet Name

DOG or CAT?

Breed

Color

Age/Date of Birth

Sex

Spayed or Neutered?

YesNo

Do you need to register multiple pets?

YesNo

Pet Name

DOG or CAT?

Breed

Color

Age/Date of Birth

Sex

Spayed or Neutered?

YesNo

Pet Name

DOG or CAT?

Breed

Color

Age/Date of Birth

Sex

Spayed or Neutered?

YesNo

Social Media Release

We love to share our patient photos with thepublic via our website, Facebook, etc. Do you give permission for us to use your pet’s photos?*

YES, My pet was born to be a star!NO, My animal is shy.

*Cancellation/Reschedule Policy**

(initial)

We require a 24 hour notice for all cancellations and rescheduled appointments. As a courtesy to others, we reserve the right to reschedule the appointment if you are more than 15 minutes late.

*Please note that if you have 2 rescheduled appointments with less than a 24 hour notice, we will require a deposit for any future appointments to be scheduled.

*Please Be Kind to Our Staff**

(initial)

Our employees have the right to be treated with dignity and respect at all times. There is a zero tolerance for all forms of aggressive behavior i.e. abusive/foul language, physical assault, verbal harassment, threats, failure to respond to staff instructions, etc.

*Vaccination Policy* *

(initial)

We are a clinic that requires vaccinations as recommended by the veterinary team. These are not optional and we will not recognize titer testing in place of vaccinations. If you do not agree with vaccinating your pets, we may not be the clinic for you. In the state of TN, rabies is required by law. If your pet is deemed healthy, we will require rabies be kept up to date per the state of TN. NO EXCEPTIONS. (unless medically exempt by a veterinarian).

*AI Scribe* *

(initial)

We use an AI scribe to create accurate, efficient medical documentation.

Medical Release

I First Name* Last Name* give Companion Animal Hospital permission to release my pet(s) medical/vaccine records at any time a request is made. Furthermore, I realize I must request in writing when I no longer wish this to be in effect.

Name & Number where we can obtain previous records*

Licensing Board Rule 1730-01-13 (6) specifically states that client records can only be released with the written permission of the client. The Board has stated that this includes requests of vaccination records from other veterinarians, groomers, and boarding facilities. For more information about this Rule, please see the Board's Policy Statement regarding Release of Patient Records at Board of Veterinary Medical Examiners-TN.gov

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pets. I assume responsibility for all charges incurred in the care of these animals. I also understand these charges will be paid at the time of patient release and that a deposit may be required for surgical treatment. By signing this form, you acknowledge our clinic polices.

Owner Signature*

Date*

Date