New Patient Registration Thank you for giving Dogwood Park Animal Clinic the opportunity to care for your pet(s). APPOINTMENT 7 To ensure the best care possible, please fill out this form completely. Please enable JavaScript in your browser to complete this form.Owner's Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneWhich number is best to reach you? *HomeCellCan you receive text messages? *YesNoEmail *Add a Co-Owner? *YesNoName *FirstLastHome PhoneCell PhonePrevious VetPrevious Vet's Phone NumberWhom should we thank for referring you? PET HEALTH HISTORYPet's Name *Sex *MaleFemaleNeutered/Spayed? *YesNoBreed *Color *Birthdate or Age *Current MedicationsPlease bring and give any medical records/vaccine records to the receptionists to make copies.DIET AND ENVIRONMENTWhat food does patient currently eat? *Amount and frequency? *Is your pet on any dietary supplements? *YesNoIf so, what kind and what dosage? *Does your pet consume table food? *YesNoPlease explain: *Is your pet primarily indoor or outdoor? *IndoorOutdoorAre there any other animals in the household? *YesNoPlease describe: *Do you have your pet groomed or boarded outside of your home? *YesNoIf so, how often? *Do you travel outside of Georgia with your pet? *YesNoIf so, where? *PAST HISTORYHas your pet had any prior illnesses, accidents, or surgeries? *YesNoPlease explain:Is your pet aggressive or fearful around strangers? *YesNoPlease explain: *Is your pet on heartworm or flea/tick preventatives? *YesNoHow frequently? *Year-roundSeasonallyPlease list any other medications or supplements your pet receives:Does your pet have any known allergies to any medications? *YesNoIf yes, please list: *Has your pet ever had a reaction to any vaccines? *YesNoIf 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? *YesNoI 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 agreeEmergency Contact *FirstLastEmergency Contact Phone *Clear SignatureDate *File Upload Click or drag files to this area to upload. You can upload up to 5 files. WebsiteSubmit