New Client / Patient Form

* indicate a required field

    CLIENT INFORMATION

    Title




    State*




    Would you like to receive our educational newsletter*?
    YesNo

    Would you like email reminders instead of postcards?*
    YesNo

    How would you like us to contact you?*

    Where else have you heard about Tidewater Veterinary?

    PET INFORMATION

    Species*

    Sex*

    Spayed/Neutered*

    Do you have a second pet?
    YesNo

    Species*

    Sex*

    Spayed/Neutered*

    Do you have a third pet?
    YesNo

    Species*

    Sex*

    Spayed/Neutered*

    Do you have a fourth pet?
    YesNo

    Species*

    Sex*

    Spayed/Neutered*

    Social Media

    HOSPITAL FINANCIAL POLICY
    Full payment is required at the time services are provided. I understand that upon my request the hospital staff will provide an estimate of any current and/or anticipated charges.

    By checking this box I am authorizing veterinary care to be provided for the pet(s) provided by me or by agent(s). I am the legal owner/agents of this/these pet(s) and as owner/agent I understand that I am financially responsible for all services provided.