Request an Appointment

1
Have we seen you or any of your pets within the past 24 months?
YESNO
2
Is your pet an existing patient or a new patient?* This field is required.
Existing Patient
New Patient
3
Appointment Type* This field is required.In-Person Appointment: You and your pet visit us at the hospital. The normal way you're probably already used to, in other words. Virtual Care: A virtual appointment (talk, text, or video chat) on your smartphone, tablet, or computer. This is a great option for questions about managing chronic conditions (examples: diabetes, arthritis, allergies), minor illnesses, for behavior consultations, or pet care questions. You must have an internet connection.
In-Person
Virtual Care
4
What's your name?* This field is required.
First Name
Last Name
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Cell Phone Number* This field is required.
Area Code
Phone Number
7
Email* This field is required.
example@example.com
8
What is your preferred method of communication?* This field is required.(choose one)
Text
Email
9
What Type of Phone is Your Primary Number?* This field is required.
Mobile
Home
Work
10
Secondary Phone Number(leave blank if not applicable)
Area Code
Phone Number
11
What Type of Phone is Your Secondary Number?
Mobile
Home
Work
12
How Did You Hear About Us?* This field is required.
Referred by a friend or family member
Found online
Referred by another veterinarian or veterinary practice
Referred by a breeder or groomer
Other
13
If Someone Referred You:Please let us know who!
Name of Referrer
14
Do you share ownership of your pet(s) with a spouse or another person?
YESNO
15
What's your pet's name?* This field is required.The pet that you are requesting an appointment for.
16
What is the reason for your pet's visit? * This field is required.Please list any information or include anything that may be helpful for your pet's visit.
Huge
Large
Normal
Small
Ok
Ok
17
Which day of the week works best for you? Select all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
No preference
18
Do you have a preferred doctor for your pet's appointment? Select all that apply.If none are selected, the client service team will select the most appropriate time and doctor based on your pet's needs.
Dr. Ken Brunson
Dr. Emily Benedict
Dr. Susan Dextradeur
Dr. Joel Harrington
Dr. Jim Mathias
Dr. Jacob Mathias
Any of the above
19
{Pet1}'s Species
Dog
Cat
Rabbit
Bird
Ferret
Other
20
{Pet1}'s Date of BirthIf you know your pet's date of birth, please enter it below. If you're not sure of the date of birth, please estimate your pet's age. For example, if you know your pet is about 4, put today's date but 4 years ago.
Date
Month
Day
Year
21
{Pet1}'s Breed
22
{Pet1}'s Colors/Markings
23
{Pet1}'s gender
Male
Female
Unknown
24
Spayed/NeuteredHas this pet been fixed?
Yes
No
Unknown
25
Do you have pet insurance for {Pet1}?* This field is required.
None
Trupanion
Nationwide
Pumpkin
Other
None
26
{Pet1}'s Medical RecordsIf you have medical records outside of what we currently have, please use this tool.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
27
Would you like to schedule for another pet?
YESNO
28
Second Pet's Name* This field is required.
29
{Pet2}'s Species* This field is required.
Dog
Cat
Rabbit
Bird
Ferret
Other
30
{Pet2}'s Date of BirthIf you know your pet's date of birth, please enter it below. If you're not sure of the date of birth, please estimate your pet's age. For example, if you know your pet is about 4, put today's date but 4 years ago.
Date
Month
Day
Year
31
{Pet2}'s Breed
32
{Pet2}'s Colors/Markings
33
{Pet2}'s gender* This field is required.
Male
Female
Unknown
34
Spayed/Neutered* This field is required.Has this pet been fixed?
Yes
No
Unknown
35
Do you have pet insurance for {Pet2}?* This field is required.
Trupanion
Nationwide
Pumpkin
Other
None
36
{Pet2}'s Medical RecordsIf you have medical records for your second pet you would like to upload, please use this tool.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
37
Has another veterinarian or veterinary practice provide your pet(s) with medical care?
YESNO
38
Please let us know who has treated your pet(s) previouslyName, location, phone number - whatever information you have may be useful in providing your pet(s) proper treatment.
Huge
Large
Normal
Small
Ok
Ok
39
Is there anything else you need to tell us at this time?
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Large
Normal
Small
Ok
Ok
40
Acknowledge and Sign to Submit A complete, up to date list of our policies and procedures can be found at Client Rights and Responsibilities Payment We will gladly prepare a written treatment plan of all estimated service fees at your request. Please discuss with us any financial limitations; we are happy to work within your budget to provide care for your pet! All professional fees are due at the time services are rendered. We accept the following forms of payment: cash, personal checks, Visa, MasterCard, American Express, Discover, CareCredit, and ScratchPay. Payment plans are available through ScratchPay and CareCredit. Returned checks will be electronically re-presented to your account along with the state allowable fee. Your use of a check represents your acceptance of this policy. See payment option details here. By signing below, you acknowledge that you understand our payment policy and verify that all of the information you provided is accurate. Pet Photo Release I grant to Tipp City Veterinary Hospital, its representatives and employees the right to take photographs of my pet, to copyright, use and publish the same in print and/or electronically. I agree that Tipp City Veterinary Hospital may use such photographs of my pet for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Clear
41
A $68 deposit is required to schedule your first appointment. Please call our office at 937-667-8489 to set up your first appointment.

We are open Monday through Friday 7:30 AM - 6:00 PM, Saturday 8:00 AM - 4:00 PM, and Sunday 10:00 AM - 4:00 PM.
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