Client Registration Form
We welcome you as a new client to
Tarpon Woods Veterinary Medical Center
Outstanding Veterinary Care for Your Loved One
Owner Information:
New Client ______ Previous Client _______ When? ________
Owner Name:_______________________________________________________________
Spouse or Co Owner:_________________________________________________________
Address:___________________________________________________________________
City: ______________________ State: ______________ Zip: ____________
Phone: ____________________ E-Mail Address:__________________________________
Driver’s License # ___________________________________________________________
How were you referred to us___________________________________________________
Owner Employer: ___________________________________________________________
Employer Phone # :__________________________________________________________
Emergency Contact : ________________________________________________________
Emergency Phone: __________________________________________________________
Pet Information:
Name Date of Birth Breed Color Sex Neutered/Spayed
(Approximate age)
-
________________________________________________________________________
-
________________________________________________________________________
-
________________________________________________________________________
-
________________________________________________________________________
Current Medications: _________________________________________________________
Any Known Allergies: _________________________________________________________
Pet Insurance Information: _____________________________________________________
Microchip or Tattoo Number : __________________________________________________
I authorize the veterinarian to examine, prescribe for and treat any of my pets on file with Tarpon Woods Veterinary Medical Center. I assume financial responsibility for all charges incurred in the care of these animals. I also understand that these charges are due and will be paid at the time services are rendered and that a deposit may be required for emergency or surgical treatment. There will be a monthly 1.5% finance and $2.00 posting charge applied to all accounts that are left unpaid.
Signature: _______________________________________ Date: _______________
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