Client FormThank you for giving us the opportunity to care for your pet(s). To allow us to become better acquainted, please fill out the following form. Thank you! Client Information Owner's First Name Owner's Last Name Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*NameIn case of your absence, is there anyone other than the above mentioned who may authorize treatment of your pet? Name:PhoneName:PhonePatient InformationPet #1NameBreedAny previous illness or surgeries?Date of Birth:Allergies?SexSpecial diets or medications?Microchip ID Pet #2NameBreedAny previous illness or surgeries?Date of Birth:Allergies?SexSpecial diets or medications?Microchip ID All fees are due at the time services are rendered.I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume all responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatments. How did you hear about East Tennessee Veterinary Hospital?PhoneThis field is for validation purposes and should be left unchanged.