Download the form here or fill out below. Client InformationName(Required) First Last Spouse/Partner First Last Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number(Required)Secondary Phone Number(Required)Place of Business Email(Required) Secondary Contact for Emergency or Authorized Pickup First Last ER Contact Phone(Required)How Did You Hear About Us?Select an optionGoogleYelpFriend/FamilyPassed-By HospitalOtherReferred by Please SpecifyEssential Pet InformationPet Name(Required) Species(Required) Breed Age (DOB) Color Sex Male Female Spayed/Neutered Yes No Add a second pet?(Required) Yes No Pet Name(Required) Species(Required) Breed Age (DOB) Color Sex Male Female Spayed/Neutered Yes No Add a third pet? Yes No Pet Name(Required) Species(Required) Breed Age (DOB) Color Sex Male Female Spayed/Neutered Yes No Add a fourth pet? Yes No Pet Name(Required) Species(Required) Breed Age (DOB) Color Sex Male Female Spayed/Neutered Yes No If your pet(s) travel (or have traveled) out of the area, where? AUTHORIZATIONUntitled I am the owner of the listed animal(s) and assume responsibility for all charges incurred in the care of this animal(s) including any collection and/or attorney’s fees. I understand that unpaid balances will accrue interest at 18% APR and a $35.00 fee will be charged for return checks. To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines (DHLPPC, Rabies and Bordatella for dogs: FVRCP and Rabies for cats) and free of internal and external parasites. If vaccinations cannot be verified, I understand that the doctor will provide vaccines and parasite control as needed and I as owner shall be responsible for these charges. Hospitalization and boarding can be stressful for pets. Pets may experience gastrointestinal upset (vomiting and/or diarrhea) and occasionally hidden medical problems can be exposed, especially in the geriatric patient. I understand that any problem that develops with my pet will be treated as deemed best by the staff veterinarians, and I assume full responsibility for the treatment expense involved. I understand that payment is due at the time services are rendered and that a deposit may be required for surgical procedures and hospitalization. We will gladly prepare a written estimate. Please ask the doctor or receptionist. We appreciate you entrusting us with the care of your pet. We understand that having a sick pet is often an emotional time. The best veterinary-client relationships are based on trust, communication and mutual respect. We want what is best for your pet! We will treat you and your pet with kindness, and ask that you do the same to our team. Abusive language, threats, as well as racist, sexist or homophobic language will not be tolerated. Please let us know if you have any concerns or questions.(Required) I understand the above. Cancelled Appointments and DepositsAs you may know, there is a high demand for veterinary care at our hospital and at veterinary practices across the country. Due to an increase in the number of last-minute cancellations and no call/no show appointments, we are instituting a new policy, which will allow us to help more pets in need of care. We now require at least 24 hours’ notice for cancelled appointments and services, because if we know there is an opening, we can offer that slot and provide needed veterinary care to another patient.Cancellation policy If you don’t cancel 24 hours before your appointment and you do not show up, we will require a deposit in the amount of our exam fee before your next appointment. This deposit will be applied to your visit at checkout but is non-refundable if the subsequent appointment is also missed. As an alternative to an appointment, you have the ability to book a drop off appointment for your pet in the morning and there would be no deposit required Drop offs are required to be up to date on vaccinations and preventions, while also not suspected to be contagious. If you don’t cancel a surgery at least 48 hours before you are expected and you do not show up, we will require a deposit before rescheduling the procedure. The deposit will be applied to the cost of the surgery at checkout but is non-refundable if missed. If you don’t cancel a boarding reservation at least 48 hours before you are expected and you do not show up, we will require a $50 per pet deposit before making a reservation for subsequent boarding. The deposit will be applied to the cost of boarding at checkout but is non-refundable if missed. Boarding deposits will be required for holidays and peak boarding times, such as Christmas, Spring Break, etc. If you have any questions about this policy or would like to make an appointment for your pet, please call us at 770-965-3773.(Required) I understand the above Cancellation Policy. Owner(Required)Date(Required) MM slash DD slash YYYY CAPTCHA Δ
