Primary Owner *

First

Last

For Medications - Client Date of birth

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Other Phone

Email *

What is your preferred method of contact? *

Emergency Contact *

Emergency Contact Phone *

Relationship *

Pet Information

Pet's Name *

Species *

Cat
Dog

Breed *

Birthdate/Age *

Color *

Gender *

Male
Female

Spayed/Neutered *

Yes
No

Does your pet have a microchip? *

Yes
No

Microchip Number: *

Known Allergies/Drug reactions? *

Yes
No

If yes, please describe: *

Other Information

Can we share pictures of your pet on our social media and/or for internal use? *

Yes
No

In addition to the telephone, we communicate via third-party text and email messages. Do you consent to text and email reminders and other messages? *

Yes
No

How did you become aware of our hospital? *

Personal referral who may we thank? *

Other: *

Is there a veterinarian or veterinary hospital you would like us to send your pet's medical records to? *

Yes
No

If yes, where and to whom would you like the records sent?

Authorization

I authorize the release of my pet's previous medical records to Tell Tail Veterinary Urgent Care. I, the undersigned, grant permission for the veterinarians and staff at Tell Tail Veterinary Urgent Care to conduct any necessary examinations, diagnostics, treatments, and/or surgeries for my pet. I understand that while every effort will be made to ensure my pet's health and safety, all procedures carry some level of risk. I acknowledge that no guarantees regarding treatment outcomes have been provided and agree to adhere to the treatment plan and recommendations from the veterinary team. *

I have read and understand.

I confirm that I am at least 18 years old and fully authorized to make decisions regarding the care of the above pet. I understand that payment is due at the time services are provided. Tell Tail Veterinary Urgent Care accepts cash, credit cards, Care Credit, Scratchpay, and debit cards. I agree to pay in full for all services, medications, and products at the time of service unless alternative arrangements have been made beforehand. In the event of non-payment, I understand that Tell Tail Veterinary Urgent Care may pursue the collection of any outstanding balance through legal means. Tell Tail Veterinary Urgent Care by law, asks for your date of birth in order to legally prescribe controlled substance prescriptions for your pet if deemed necessary by a Veterinarian. This information is kept confidential and exclusively used for providing the dispensing information to the Department of Justice., pursuant to Business and Professions Code Section 4170 and Section 11190 of the Health and Safety Code. *

I have read and understand.

Signature *

Clear Signature

Today's Date *

New Client Form

New Client Form

Pet Information

Other Information

Authorization

Contact US

Contact

Location

Hours