Peachtree City New Client Form - The Animal Medical Clinic

1

Client Info* This field is required.

Pet Name

Owner

Email

2

Please select ONE of these Two Options if Your Pet Becomes Sick

I authorize the attending veterinarian to administer treatment and perform diagnostic testing as is considered medically necessary. I also consent to the administration of such anesthetics or sedatives and surgical procedures only if deemed to be an emergency by the attending veterinarian. I understand that the Animal Medical Clinic will make every attempt to contact me prior to treatment should medical and/or surgical care of an emergency nature be required.

I only authorize basic treatment (medications such as anti-diarrheal or pain medication) as necessary to keep my pet comfortable until I can be contacted. I understand that the Animal Medical Clinic will make every attempt to contact me should my pet become ill and require treatment.

3

Emergency Number(s)* This field is required.Separate with comma (,)

4

Please acknowledge and initial consent to the following:

Please Initial * Even though all dogs are vaccinated, your dog may get ill (i.e. cold, diarrhea, eye infection, etc.)

5

Day Play?* This field is required.

Yes

No

6

If yes, please review and initial beside the following to ensure your understanding and consent.
    Please Initial *    Even with diligent care and monitoring, your dog may get injured or bit while playing.
    Please Initial *    You will be financially responsible for medical care your dog may need if nipped during play, injured while playing (i.e. scraped, bruised, sprained), or develops an illness (i.e. cold, diarrhea, eye infection, etc.)
Do we have your permission to post your dog’s photo on our social media sites.    *
    Please Initial    if permission to post on social media sites is granted.

7

Food & Feeding Instructions

Your Dog Food

Feedings Instructions

Daily Medication(s)

8

If yes, medicine name and administration instructions* This field is required.

9

Special/Additional Concerns

10

Owner Signature* This field is required.

Clear

11

Date* This field is required.

Date