Tri County Animal Hospital

22285 St. Rt. 62 E
Alliance, OH 44601

(330)821-0397

www.tri-countyanimalhospital.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

Name *(required)*

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary Practice?

Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No

Would you like us to call you for your appointment?

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this pet. I also understand that these charges will be paid at the time of service and that a deposit may be required for hospitalization and/or surgical treatment.

Please Read

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HOURS

Day	Open	Close
Monday	8:00 am	5:00 pm
Tuesday	8:00 am	5:00 pm
Wednesday	8:00 am	5:00 pm
Thursday	8:00 am	5:00 pm
Friday	Closed	Closed
Saturday	Closed	Closed
Sunday	Closed	Closed

We are a small and exotic animal AAHA Accredited Veterinary Hospital proud to provide a high standard of care for your pets!

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