Veterinary Medical Referral Clinic of Tacoma
Practice Specializes in Internal Medicine by Referral and Appointment
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For New / Existing Clients
:
New Patient - Submit Electronically
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Form - New Patient - Submit Online
Owner Information
(required)
First Name
(required)
Last Name
(required)
Address
(required)
Street Address
(required)
City
(required)
State/Province
(required)
Zip/Postal Code
(required)
,
Primary Phone
(required)
Phone Type
Phone Number
(required)
Cell
Fax
Home
Work
Secondary Phone
Phone Type
Phone Number
Cell
Fax
Home
Work
Other Phone
Phone Type
Phone Number
Cell
Fax
Home
Work
E-mail Address
E-Mail Address :
Employer
Employer
Occupation
Spouse or Other Authorized Care Taker
First Name
Last Name
*Please note: Information can only be released to authorized care takers.
Phone
Phone Type
Phone Number
Cell
Fax
Home
Work
Patient Information
Pet's Name
(required)
Species
(required)
Canine
Feline
Breed and Color
(required)
Date of Birth
(required)
Approximate Age
(required)
Sex
(required)
Male
Female
Spayed / Neutered
(required)
Yes
No
Unknown
Microchipped
Yes
No
Unknown
Microchip Number
Referring Veterinarian
Referring Clinic
Referring Veterinarian
*Please note the following policy:
Payment is due at the time of service. A deposit will be required for patients that are admitted to the clinic for diagnostic tests or treatment. You may pay by cash, check (subject to approval), VISA, Discover, or MasterCard. In order to avoid any misunderstandings about fees/payment or if you have any questions, please discuss your concerns with a staff member before services are performed.
I agree to the above policy.
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Veterinary Medical Referral Clinic of Tacoma
2505 S. 80th Street
Tacoma, WA 98409
(253)475-5301