Tranquility Veterinary Clinic

Owner Name*

First NameLast Name
Are you a...*

Existing ClientNew Client
Previous vet's name*
Previous vet phone number*
If you have medical records for your pet(s), please upload them here. These records help us provide the best care for your pet(s) by ensuring we have accurate information about their health history, vaccinations, and any ongoing treatments.

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Co-Owner Name

First NameLast Name
Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Phone Number*
Please enter a valid phone number.
Co-Owner Phone Number
Please enter a valid phone number.
Owner Email Address*
example@example.com
Co-Owner Email Address
example@example.com
How would you prefer to receive reminders?*

EmailTextBoth Are Fine
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you hear about us?*

GoogleYelpWalk ByFacebookInstagramShelter/RescueClientEmployeeOther Hospital/DoctorOther
If Shelter/Rescue/Client/Employee/Other Hospital/Doctor, who can we thank for the referral?*
Appointment Type

Wellness (vaccines, bloodwork, etc)ExoticAcupunctureLibrela injection (for dogs)Solensia Injection (for cats)Laser TherapyEuthanasia
Pet Information
Pet #1
Pet Name*
Pet birthday or estimated age*
Color/Description*
Species*

DogCatOther
Breed*
Sex*

MaleFemaleUnknown
Spayed/Neutered*

YesNo
Microchipped?*

YesNo
We take special care when scheduling our nervous patient exams. We want to set you and your pet up for a successful visit and ensure that we can provide the best care possible. Does your pet have a history of fearful, anxious, or aggressive behavior during a hospital visit or has required anti-anxiety medications or sedatives in the past? Please answer yes or no, and if yes, please explain.*
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?

YesNo
Pet #2
Pet Name*
Pet birthday or estimated age*
Color/Description*
Species*

DogCatOther
Breed*
Sex*

MaleFemaleUnknown
Spayed/Neutered*

YesNo
Microchipped*

YesNo
We take special care when scheduling our nervous patient exams. We want to set you and your pet up for a successful visit and ensure that we can provide the best care possible. Does your pet have a history of fearful, anxious, or aggressive behavior during a hospital visit or has required anti-anxiety medications or sedatives in the past? Please answer yes or no, and if yes, please explain.*
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?*

YesNo
Pet #3
Pet Name*
Pet birthday or estimated age*
Color/Description*
Species*

DogCatOther
Breed*
Sex*

MaleFemaleUnknown
Spayed/Neutered*

YesNo
Microchipped*

YesNo
We take special care when scheduling our nervous patient exams. We want to set you and your pet up for a successful visit and ensure that we can provide the best care possible. Does your pet have a history of fearful, anxious, or aggressive behavior during a hospital visit or has required anti-anxiety medications or sedatives in the past? Please answer yes or no, and if yes, please explain.*
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?*

YesNo
Pet #4
Pet Name*
Pet birthday or estimated age*
Color/Description*
Species*

DogCatOther
Breed*
Sex*

MaleFemaleUnknown
Spayed/Neutered*

YesNo
Microchipped*

YesNo
We take special care when scheduling our nervous patient exams. We want to set you and your pet up for a successful visit and ensure that we can provide the best care possible. Does your pet have a history of fearful, anxious, or aggressive behavior during a hospital visit or has required anti-anxiety medications or sedatives in the past? Please answer yes or no, and if yes, please explain.*
What is the reason for your visit?*
Please list any medical conditions your pet has:
We understand that this is an emotionally difficult time for you and your family, and with that in mind, we offer some options to help make this decision as easy as possible. Please review and initial the following:
In signing this release, I authorize Tranquility Veterinary Clinic to euthanize my pet, knowing this is an irreversible procedure.*

YesNo
I understand that I have the option to be present during the procedure. I can also choose not to be present, and be assured that a gentle and kind approach will be used.*

YesNo
Although euthanasia is typically a painless procedure, I realize that it may be difficult in an excited or stressed pet. A pre-euthanasia injection may be given before the procedure to keep my pet calm.*

Yes, please administer.No, do not administer.
I request that my pet's remains be cared for in the following manner:*

Private cremation with return of ashes.Cremation with no return of ashes. My pet's remains will not be returned to me.Home burial. I wish to take my pet's body home.
I certify that my pet has not bitten any person or animal within the last 10 days.*

My pet has NOT bitten a person or animal in the last 10 day.My pet HAS bitten a person or animal in the last 10 days.
Payment Policy
Please note that payment is required in full at the time services are rendered. If you have any questions or concerns regarding payment, please feel free to contact us before your appointment. Thank you for your understanding and cooperation.

Deposit/Reservation fee is required for all House call appointments and is applied to your final payment after the appointment is finalized.
I have read and understand this authorization and fees have been explained to me. Please initial below:*
Cancellation Policy
Cancellation must be made via phone call or email 48 hours prior to visit to receive a full refund, 24 hours prior you will receive a 50% refund.
I HAVE READ AND UNDERSTAND THE ABOVE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW.*

I agreeI do NOT agree
(Owner) Parent or Guardian Name*

First NameLast Name
(Owner) Parent or Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Pet Information

Pet #1

Pet #2

Pet #3

Pet #4

Payment Policy

Cancellation Policy