NEW CLIENT FORM

New Client form

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New Client Form
File Size:	102 kb
File Type:	pdf

New Client form

owner information

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

How did you hear about us? *

Pet Information

Pet Name *

Date of Birth *

Breed *

Choose One *

Male Intact Female Intact Male Neutered Female Spayed

Color/Markings *

When was the last time your pet went to the vet for routine wellness care? *

What is your pet's vaccination status? *

Where can we call to obtain your pet's previous medical history? *

Does your pet have preexisting medical conditions? *

Yes No

Is your pet taking any medications? *

Yes No

If Yes, please list medical condtions. *

If Yes, please list medications. *

Does your pet have any medical/food allergies or sensitivities we need to be aware of? *

Yes No

If Yes, please list allergies. *

Do you have any concerns you would like to address with the doctor? *

I understand it may be necessary to shave some of my pets hair in order to collect samples, administer treatments, and/or surgical procedures. We endeavor to shave as little as possible *

Yes

Tardy/No-Show/Insufficient Cancellation Agreement

Thank you for trusting Tangerine Pet Clinic with your pet’s care. We value our relationship and are committed to providing you and your pet with comprehensive, quality care. In light of this, we seek to maximize your care experience, minimize waiting time, and create a more efficient and harmonious environment. Being late to a scheduled appointment can negatively impact your and and your pet’s experience, the care of our subsequent patients, and our team. Insufficient notice to cancel or reschedule impacts our ability to accommodate appointments for pets/owners with urgent scheduling needs. These mutual goals requires us to establish a Tardy/No-Show/Insufficient Cancellation Agreement as follows: Client Responsibilities: Please be prompt. Clients arriving 15 minutes or more after their appointment time may be asked to reschedule, wait for the soonest available appointment, and/or be offered a drop-off appointment.

I have read and understand. Initials: *

Should you need to cancel or reschedule, please contact our office as soon as possible and no later than 24 business hours prior to your scheduled appointment. We understand same-day scheduled appointments are not able to provide 24 hour notice. Clients who fail to do so will be asked to provide a $25.00 deposit prior to rescheduling their appointment. We understand that there may be special unavoidable situations that prevent your from providing us with 24 hour notice. In such cases, we may waive the fees with managerial approval.

I have read and understand. Initials: *

Clients who fail to give appropriate cancellation/rescheduling notice, and no call/no show, for their appointment will be asked to provide a deposit in the amount of the exam fee prior to scheduling their next appointment. Excessive no-shows may result in client dismissal.

I have read and understand. Initials: *

Please verify and update contact information, so we can effectively communicate reminders or scheduling updates.

I have read and understand. Initals: *

Please respond to appointment confirmation correspondence.

I have read and understand. Initials: *

Exceptions: We understand that emergencies and unforeseen circumstances can arise. Please contact our office as soon as possible to discuss these situations.

I have read and understand. Initials: *

We will make every effort to be timely and respectful of your time. Should patient emergencies impact our schedule, we apologize in advance for any inconvenience, and will keep you informed. We will provide comprehensive reminders via email, text messaging, and phone calls.

I have read and understand. Initials: *

Informed consent for controlled substances

Controlled substances are medications with a high potential for abuse and/or dependence. The federal government regulates them due to these risks. Examples include opioids (pain medications), certain stimulants, and anti-anxiety medications.
Tangerine Pet Clinic focuses on providing effective care, without prescribing controlled substances. We believe in exploring alternative treatment options that minimize the risk of abuse.
We are committed to offering various treatment options that don’t involve controlled substances such as: non-opioid pain medication and behavioral therapies.

I have read and understand. Initals: *

Informed for prescription refills

I understand that Tangerine Pet Clinic will not authorize refills for prescription medications for more than 12 months at a time. For chronic conditions, I understand the need for regular follow-up appointments, and prescription refills will be authorized for 6 months or less to help ensure patient’s health and effectiveness of the medication. Therefore I agree to the following:
To schedule a follow-up appointment for my pet at least every 6 months or more frequently as health warrants. To complete any necessary laboratory tests. I understand that if I do not schedule a follow-up appointment or complete the required labs, my refill request may be denied.

I have read and understand. Initals: *

Financial Policy

Our policies regarding payment with our office. We accept Credit/Debit Cards, Cash, or Care Credit. You must be 18 years of age or older and you assume full financial responsibility for all agreed to services.
If you have insurance (other than Trupanion) you will be expected to make a full payment on the day of your visit. If you have Trupanion, a claim can be submitted for that day’s visit, and you will be expected to make payment in full amount of invoice that Trupanion did not cover.
For patients admitted for diagnostics, treatments, and/or surgery, payment will be required at time of admittance.
For new clients scheduling an appointment, a deposit will be taken in the amount of the exam fee.
For clients scheduling an appointment for a surgery/dental, a deposit will be taken.
I have read and understand the payment policies set forth and I understand my responsibility for payment with Tangerine Pet Clinic.

I have read and understand. Initals: *

Social Media consent

I hereby give Tangerine Pet Clinic permission to take photographs and videos of my pet for the purpose of posting on Tangerine Pet Clinic’s Facebook, YouTube, Twitter, Instagram, and clinic Website.
I hereby release and discharge Tangerine Pet Clinic from any and all claims arising out of use of the photos.
Tangerine Pet Clinic has my permission to use my pet’s name. Only your pet’s first name will be used , never your first name or last name, or that of any of your family members. We will only use your pet’s likeness we will never use you or your family’s likeness. Your pet’s medical condition will never be used in our posts.
In signing this consent, I give permission to use my pet’s name as printed below.

Pet's name: *

I agree to all terms on this form, and this serves as my legal binding signature. *

First

Last

Please enter first and last name below

Date: *

Please enter date this form is being completed below.

Submit

Tangerine Pet Clinic
12090 N Thornydale Rd, Ste 104
Marana, AZ 85658

P. (520) 848-DOGG (3644)
F. (520) 308-5348
[email protected]

, Business Hours
Monday - Friday:
9:00am - 5:00pm

Saturday:
9:00am - 3:00pm
(Open Saturdays below)

Sunday:
Closed

Doctor's Hours by appointment only*

Memorial Holiday Hours
Closed - Saturday 5/24/25
Closed - Monday 5/26/25

4th of July Holiday Hours
Closed - Friday 7/4/2025
Closed - Saturday 7/5/25

Labor Day Holiday Hours
Closed - Saturday 8/30/25
Closed - Monday 9/1/25

Thanksgiving Holiday Hours
Closed - Thursday 11/27/25
Closed - Friday 11/28/25
Closed - Saturday 11/29/25

Christmas Holiday Hours
Closed - Thursday 12/25/25

New Years' Holiday Hours
Closed - Thursday 1/1/26

Open on the following Saturdays in 2025:

2/15/2025
3/1/2025, 3/15/2025
4/12/2025, 4/26/2025
5/3/2025, 5/17/2025
6/7/2025, 6/21/2025
7/12/2025, 7/26/2025
8/9/2025, 8/23/2025
9/13/2025, 9/27/2025
10/4/2025, 10/18/2025

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Home
SERVICES
ABOUT
- MEET OUR STAFF
- TOUR OUR FACILITY
CONTACT
Blog
SNAKE AVOIDANCE TRAINING
MEET OUR STAFF
NEW CLIENT FORM