New Client Registration - Two Rivers Veterinary Clinic

Primary Guardian(Required)

First Last

Co-Guardian

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Co-Guardian Phone

Email (primary)(Required)

Email is an important tool for all communications, including appointment confirmations, reminders, and clinic newsletters.

Email (co-guardian)

Email is an important tool for all communications, including appointment confirmations, reminders, and clinic newsletters.

How did you hear about us?

Current Primary Veterinary Clinic(Required)

Were you referred here by your veterinarian?(Required)

Yes

Name(Required)

Would you like to receive vaccine reminders from us? (Check no if keeping a primary veterinarian for wellness care)(Required)

Yes

Pet Name(Required)

Species(Required)

Canine

Feline

Breed(Required)

Sex(Required)

Male

Female

Spayed/Neutered?(Required)

Yes

Date of Birth/Age(Required)

Microchip ID(Required)

Color & Identifying Markings(Required)

Is your pet currently on any medications(please include flea or heartworm medications)?(Required)

Yes

Has your pet ever had a severe allergic reaction to anesthesia, vaccination, medication or food?(Required)

Yes

Has your pet ever had a severe illness or surgery?(Required)

Yes

Fee Policy and Consent for Treatment:

All new client appointments are $185, with a non-refundable deposit of $100 required to schedule. If your initial visit is rescheduled with less than two business days notice, or in the event of a no-show, your deposit will be treated as a late cancellation fee. A $60 fee will be assessed for all future cancellations made less than 24 hours in advance.

I give the veterinarian permission to examine, treat, and/or medicate my pet. I consent to the use of alternative medical therapies for my pet, including but not limited to: acupuncture, chiropractic, cold laser therapy, herbal formulas, and nutritional supplements.

I have read and understand the above fee policy and consent for treatment. I accept financial responsibility for all charges incurred in the care of my pet, and understand that all fees must be paid in full at time of service.(Required)

I have read and understand

Date(Required)

Signature(Required)

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