New Client Registration Form

Owner's Name

Owner*

First Last

Spouse/Secondary Owner*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone Number*

Date of Birth

Your date of birth is required to log controlled substances prescribed to your pet in the state of California

Work Phone

Email*

Enter Email Confirm Email

How did you find out about our practice?

Emergency Contact

In the event of an emergency or natural disaster, we would like additional phone numbers of someone other than yourself in case you cannot be reached. This can be a friend, neighbor or family member.

Name*

First Last

Mobile Phone*

If Other, please specify:

Pet Information

Pet's Name*

Species*

Breed (if known)*

Color*

Date of Birth or Age (if known)*

Sex*

Microchipped*

Yes
No

Primary reason for visit*

Do you need to add an additional pet?

Yes
No

Additional Pet

Pet's Name

Species

Breed (if known)

Color

Date of Birth or Age (if known)

Sex

Microchipped

Yes
No

Primary reason for visit

Do you need to add a second, and final, additional pet?

Yes
No

Second Additional Pet

Pet's Name

Species

Breed (if known)

Color

Date of Birth or Age (if known)

Sex

Microchipped

Yes
No

Primary reason for visit

Consent

Image Disclaimer

I hereby authorize Town & Country Vet and the Pleasanton Pet Hotel to take photos of my pet(s) and post any and all photos taken to any and all social media platforms

I agree to the image policy.

Authorization Policy*

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pets(s). I assume responsibility for all charges incurred in the care of the animal(s). I also understand that all professional fees are due at the time services are rendered. We do require that all clients pay with either a credit card, cash or CareCredit.

I agree to the authorization policy.

Today's Date*

Owner's Name

Emergency Contact

Pet Information

Additional Pet

Second Additional Pet

Consent

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