Check in Form - EASTSIDE ANIMAL MEDICAL CENTER

EASTSIDE ANIMAL MEDICAL CENTER
PHONE: 678-985-5530
1835 Grayson Hwy (GA Hwy 20)
Grayson, GA 30017
FAX: 678-985-2730

Check here if you have been here before this visit
Car Description
Reason for visit
___ Military or ___ Educator (Must show identification)
Military Educator
Please upload a picture of your Military ID or Educator ID for discount.

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Owner/Agent: *
Spouse:
Primary Veterinarian (Name of Practice) *
Email *
example@example.com
Date:

Month Day Year
Date
Address *

Address

Street Address Line 2

City & State
Zip Code and County: *
Patient: *
K9 or Feline *
Breed *
Sex: *
Age: *
Birthday:
Spayed/Neutered *
Color: *
Home Phone #: *
Cell Phone #: *
Work Phone #:
Other Phone #: (Emergency Contact)
ALL PAYMENT IS DUE AT THE TIME OF SERVICE
I authorize the Doctor and or staff at EASTSIDE ANIMAL MEDICAL CENTER to administer treatment and medication as

is considered necessary. I will honor all financial commitments incurred in the diagnosis and treatment of the patient

above and understand that all financial obligations will be satisfied prior to the dismissal of the patient. I understand that
EASTSIDE ANIMAL MEDICAL CENTER will contact my primary veterinarian and will release the patient’s medical record for emergency services to my primary veterinarian. I understand that all problems may not be resolved and will arrange for follow-up care with my primary veterinarian as instructed. *

NO - DO NOT RESUSCITATE YES - PERFORM CPR
If my pet experiences cardiac and/or respiratory arrest (lack of heart beat and/or breathing), I request the veterinarians and staff of EASTSIDE ANIMAL MEDICAL CENTER to perform CPR in an attempt to restore heart and/or respiratory

function. I understand that medications, equipment, and procedures utilized during CPR attempt will be billed in addition to

the estimate given for examination, medications, and treatments – and will generally result in an additional expense of

$500.00 or greater. I have read the above authorization and fully understand the reason for medication and or treatment. I

have been informed of potential complications and the fees that will be incurred in the course of treatment.

I understand that ALL EMERGENCY CLIENTS / PATIENTS MUST RETURN to their primary veterinarian for ALL

follow-up treatment, including prescription refills. Patients not picked up by 8:00 am on day of dismissal, will
incur a late discharge fee of $20.00 per hour. All records will be sent to your primary veterinarian.
Initial: *
A monthly service fee of 1.5% will accrue on all unpaid balances.
Signature of owner or agent: *

Clear
This form MUST be signed. If this form is not signed then treatment can NOT be started on your pet and form will need to be resubmitted for completion. This may cause delays in your pets' treatment.
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EASTSIDE ANIMAL MEDICAL CENTER

PHONE: 678-985-5530

1835 Grayson Hwy (GA Hwy 20)

Grayson, GA 30017

ALL PAYMENT IS DUE AT THE TIME OF SERVICE