TCVH - New Client Form

New Client Form

Please complete this form to ensure that we are able to provide you with exceptional service.
Your Information
Your Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
What's your preferred method of communication? *

Phone Text Email
E-mail *
Primary Phone Number *

Area Code Phone Number
What type is your primary phone number? *

Mobile Home Work
Secondary Phone Number

Area Code Phone Number
What type is your secondary phone number?

Mobile Home Work
How did you hear about TCVH? *

Referred by a friend, breeder or groomer Referred by another veterinarian or veterinary practice Found online Selected from the phone book
What is the name of the person or business that referred you?
What is the name of the veterinarian or veterinary practice that referred you?
Co-Owner?
Do you share ownership of your pet(s) with a spouse or another person? *

Yes No

Co-Owner's Information
Co-Owner's Name

First Name Last Name
Co-Owner's E-mail
Co-Owner's Phone Number

Area Code Phone Number

Current or Prior Veterinarian or Veterinary Practice
Has another veterinarian or veterinary practice provide your pet(s) with medical care? *

Yes No

Acknowledgement
We will gladly prepare a written estimate of service fees if you desire. All professional fees are due at the time services are rendered. We accept the following forms of payment: cash, personal checks, Visa, MasterCard, American Express, Discover, and CareCredit. Returned checks will be electronically re-presented to your account along with the state allowable fee. Your use of a check represents your acceptance of this policy. By signing below, you acknowledge that you understand our payment policy and verify that all of the information you provided is accurate.

Pet Photo Release

I grant to Tipp City Veterinary Hospital, its representatives and employees the right to take photographs of my pet, to copyright, use and publish the same in print and/or electronically.

I agree that Tipp City Veterinary Hospital may use such photographs of my pet for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Your Signature *
Co-Owner's Signature *
Should be Empty: