New Patient Registration Form New Client: Yes NoCurrent Client, New Pet: Yes NoPet Insurance: Yes NoAuthorized 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone:Cell Phone:Email Referring VeterinarianHow 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 OtherDate of Birth Date Format: MM slash DD slash YYYY AgeSex Male FemaleSpayed Yes NoNeutered Yes NoNew Patient Name:Breed:Color: Dog Cat OtherDate of Birth Date Format: MM slash DD slash YYYY AgeSex Male FemaleSpayed Yes NoNeutered Yes NoNew Patient Name:Breed:Color: Dog Cat OtherDate of Birth Date Format: MM slash DD slash YYYY AgeSex Male FemaleSpayed Yes NoNeutered Yes NoPlease provide your previous Veterinarians contact information so we can have your pet’s medical records faxed to us (vaccination information, bloodwork, etc., needed). NamePhoneAll 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* Date Format: 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* Date Format: MM slash DD slash YYYY
