Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Which number is best to reach you? *

Home
Cell

Can you receive text messages? *

Yes
No

Email *

Add a Co-Owner? *

Yes
No

Name *

First

Last

Home Phone

Cell Phone

Previous Vet

Previous Vet's Phone Number

Whom should we thank for referring you?

PET HEALTH HISTORY

Pet's Name *

Sex *

Male
Female

Neutered/Spayed? *

Yes
No

Breed *

Color *

Birthdate or Age *

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

DIET AND ENVIRONMENT

What food does patient currently eat? *

Amount and frequency? *

Is your pet on any dietary supplements? *

Yes
No

If so, what kind and what dosage? *

Does your pet consume table food? *

Yes
No

Please explain: *

Is your pet primarily indoor or outdoor? *

Indoor
Outdoor

Are there any other animals in the household? *

Yes
No

Please describe: *

Do you have your pet groomed or boarded outside of your home? *

Yes
No

If so, how often? *

Do you travel outside of Georgia with your pet? *

Yes
No

If so, where? *

PAST HISTORY

Has your pet had any prior illnesses, accidents, or surgeries? *

Yes
No

Please explain:

Is your pet aggressive or fearful around strangers? *

Yes
No

Please explain: *

Is your pet on heartworm or flea/tick preventatives? *

Yes
No

How frequently? *

Year-round
Seasonally

Please list any other medications or supplements your pet receives:

Does your pet have any known allergies to any medications? *

Yes
No

If yes, please list: *

Has your pet ever had a reaction to any vaccines? *

Yes
No

If yes, please list and explain: *

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. *

I have read and agree.

I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment. *

I have read and agree.

Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media? *

Yes
No

I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18. *

I have read and agree

Emergency Contact *

First

Last

Emergency Contact Phone *

Clear Signature

Date *

File Upload

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New Patient Registration

We proudly service pets in Grovetown, GA and beyond!

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