New Patient Registration Form New Client: Yes No Current Client, New Pet: Yes No Pet Insurance: Yes No Authorized Owner: Spouse: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone:Cell Phone:Email Referring Veterinarian How Did You Hear About Us? (please check all that apply): TCVC Billboard TCVC Website Regal Cinemas Social Media (Facebook, Instagram, TCVC App) Yellow Pages Next Three Days TCVC Sign Google, Yahoo, etc. Existing client (name) New Patient Name: Breed: Color: Dog Cat Other Date of Birth MM slash DD slash YYYY Age Sex Male Female Spayed Yes No Neutered Yes No New Patient Name: Breed: Color: Dog Cat Other Date of Birth MM slash DD slash YYYY Age Sex Male Female Spayed Yes No Neutered Yes No New Patient Name: Breed: Color: Dog Cat Other Date of Birth MM slash DD slash YYYY Age Sex Male Female Spayed Yes No Neutered Yes No Please provide your previous Veterinarians contact information so we can have your pet’s medical records faxed to us (vaccination information, bloodwork, etc., needed). Name PhoneAll professional fees are due at the time services are renderedHOURS OF OPERATION Town and Country Veterinary Clinic & Emergency Hospital normal business and medical staffing hours: Sunday-Monday: 7:00 AM-9:00 PM This is in accordance with the amendment to the Code of Virginia 54.13806.1.Additional charges deemed necessary by a veterinarian will apply for emergency services I confirm that I have read this form and understand the staffing hours and care policies of Town and Country Veterinary Clinic & Emergency Hospital.Signature* Date* MM slash DD slash YYYY PAYMENT POLICY At Town and Country Veterinary Clinic & Emergency Hospital, we strive to provide the highest quality of medical care. Prior to any treatment, we will prepare a written estimate of the expected cost of care your pet may need. All fees incurred are the responsibility of the pet owner. All professional fees are due at the time services are rendered. We do not accept checks from new clients.There will be a $55 service charge along with associated legal fees for any check returned unpaid. We accept all major credit cards, including CareCredit. Should you need assistance applying, we would be happy to provide you with the automated telephone number prior to or during your visit. I confirm that I have read the form and understand the payment policies of Town and Country Veterinary Clinic & Emergency Hospital.Signature* Date* MM slash DD slash YYYY
