New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

How did you hear about us?

Internet Search

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

Payment is expected at the time services are rendered – No exceptions. We accept Checks ( with valid ID), MC, VISA, Discover, Care Credit, and Cash. Please make sure you are able to provide one of these forms of payment before being seen by the Doctor or Staff. Any unpaid balance is subject to an additional 40% collection fee.*

Initial

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

Pet's Name*

Age / DOB*

Species*

Breed

Color

Sex*

Female Intact

Female Spayed

Male Intact

Male Neutered

Are your pets vaccines current?

Yes

No

Do you have pets medical records?

Yes

No

Medical records at another veterinary Practice?

Yes

No

Previous Veterinarian and Phone Number

May we request a transfer of records?

Yes

No

Would you like us to call you for your appointment?

Yes

No

Reason for your pet's visit:

Special requests or conditions?

Please list any additional pets here

In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, “a written authorization or other form of waiver executed by the client or an appropriate court order or subpoena” is required in order for us to provide a copy of your pet’s medical records.

I certify that I am the owner of the patient (s) whose records are being requested, and by signing below, I hereby authorize Southeast Georgia Veterinary Clinic and Pawed Dog Hotel to release or obtain medical records on my pet(s) as deemed necessary. This shall cover all future requests.

Initials