Client and Pet Registration Form

Client Information

Client Name (first & last)

Spouse/Partner (first & last)

Address

City

State

Zip

Home Phone

Mobile

Work

Email

Agent/Co-Owner Name

Address

City

State

Zip

Home Phone

Mobile

Who may we thank for referring you today?

Pet Information

Pet's Name

DOB/Age

Breed

Color

Please select the appropriate option

Is your pet up to date on rabies vaccination?

Referring Veterinarian/Primary Veterinarian

Doctor's Name

Clinic/Hospital Name

City

State

Medical History

Briefly, please describe the reason for today’s visit.

Please describe any diseases/ conditions that your pet currently has or has had in the past.

Please list any medications your pet is currently taking. This includes vitamins, supplements.

Does your pet have allergies to medications, anesthetics, or foods? If yes, please provide details in the space provided.

Tufts Veterinary Emergency Treatment & Specialties Agreement and Consent

  • I understand that the cost of the initial exam does not cover any further diagnostic, treatment, or medication that may be necessary for my pet.
  • I understand that payment is required at the time of the service and I agree to pay for all services rendered.
  • I understand that in the event that further diagnostics or treatments are recommended by the doctor I may request an estimate of those charges first if I have not been provided one.
  • I understand that I have the right to refuse any treatment, diagnostic, or medication that has been recommended to me by my doctor.
  • I understand that any abusive or disrespectful behavior towards Tufts VETS employees may result in dismissal from Tufts VETS care.

Signature of Owner/Agent

Date

You and your doctor will be provided with a report with a report from the doctor for every examination performed on your pet at Tufts VETS. Thank you for trusting us with your pet!