Tidmore Veterinary Hospital

If you would like to place an order and have it mailed or picked up at our office, please complete the form below. Remember, you must be a current client / patient for us to dispense medication.

[Fields marked with * are required]
Client Information
* Owner’s Name
Spouse/Other
* Address
* City/State		Zip
* Home Telephone		Work Telephone
* Employer’s Name & Address
Spouse’s/Other’s Employer & Address
PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Please complete the following for identification purposes:
Driver’s License
* State		* Number
I, the undersigned, declare that I am nineteen years of age or older and promise to pay for the services rendered by Tidmore Veterinary Hospital.
* Date of Signature		*Signature
Pet Information1
* Pet’s Name
Category	Dog   Cat   Other
* Age		* Sex
Has your pet been spayed or neutered
Does your pet take any medication, if yes please list
Does your pet have any allergies to medication, if yes please list
Vaccination histroy
Is your pet	Indoors   Outdoors   Both
Pet Information2
Pet’s Name
Category	Dog   Cat   Other
Age		Sex
Has your pet been spayed or neutered
Does your pet take any medication, if yes please list
Does your pet have any allergies to medication, if yes please list
Vaccination histroy
Is your pet	Indoors   Outdoors   Both
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