New Client Info

Client Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Email *

Phone *

How Do You Prefer to be Contacted

Text

Phone Call

Were you referred by a family member or friend?

Yes

Please enter the name of who referred you.

Spouse or Co-Parent Name

Spouse or Co-Parent Phone

Spouse or Co-Parent Email

Alternate Emergency Contact Name

Alternate Emergency Contact Phone

Pet Information

Number of Pets *

Pet 1

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Pet 2

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Pet 3

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Pet 4

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Current Veterinarian

Would you like us to contact a previous vet for records for your pet?

Yes

Previous Clinic Name

Acknowledgment and Signature

I authorize Taconic Veterinary Center, to release information including diagnosis, records, lab work and x-rays of my above named pet(s). This release of information will remain in effect until terminated by me in writing. This information may be released to:

Primary Veterinarian

Emergency Veterinarian Hospitals or Referral Specialists

Insurance Company

Other

Information is not to be release to anyone

Lab Results

I grant permission for Taconic Veterinary Center to leave a message regarding laboratory results for my pet(s) listed above.

I do not grant permission for Taconic Veterinary Center to leave a message regarding laboratory results for my pet(s) listed above.

Clinic Name

Name of Insurance Company

Policy #

Other

I understand that payment is expected at the time services are rendered. I hereby authorize the staff of Taconic Veterinary Center to render any treatments which is deemed necessary to the health of my pet(s) while in custody of the hospital. I understand that in the event of unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representatives before, if time permits, proceeding with the treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that a deposit is required for al pets admitted to he hospital. I understand if my account is not kept in good standing, it will be forwarded to a third-party collection agency, which may affect my credit rating. I understand and consent that photos or videos may be taken of my pet for marketing purposes by Taconic Veterinary Center. I also acknowledge that video and audio monitoring is in place throughout the hospital and may be used for training or internal purposes. I consent to the participation of myself and any accompanying individuals in this monitoring. *

I have read and agree to the statement above.

Signature of Owner / Agent / Good Samaritan *