New Client Form New Client Pet Owner First Name * Pet Owner Last Name * Drivers License # Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Spouse Name Spouse Phone Home Phone Work Phone Cell Phone Emergency Contact Name Emergency Contact Phone Reason for Visit * How Did You Hear About Us? Pet Health History Name of Pet * Species Pet Date of Birth Breed Color * Pet Sex * Female Female Spayed Male Male Neutered Pet Microchipped? Yes No Pet Have Allergies? * Pet's Current Medications Describe Your Pet's Diet Add Remove Services At Tally Oaks Veterinary Services (TOVS) we are committed to living better through "natural" chemistry and less toxins for ourselves, our pets, and our patients. If you are interested in learning more about laser therapy (used to aid in the reduction of inflammation and improve healing), essential oils (for whole pet and body support), and/or other forms of holistic medicine don't hesitate to let us know. We look forward to reducing the toxin levels in your home and in your pets lives so they can live a healthier and happier life style. Authorization I hereby authorize the veterinarian to examine, prescribe for, or treat the above describe pet(s.) I assume responsibility for all charges incurred in care of these animals. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. I understand that if I choose to make payment with a credit card, that I will be charged an additional 3.5% of my total bill to cover credit card fees. I also understand there will be a $50 charge for no show appointments. I Agree * Yes Agreeing Client Name * Date * Submit Δ
