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  • New Client Form

    Greetings! Thank you for your interest in our practice. Please take a few minutes to fill out this form as completely as possible so we can better assist you with scheduling and services.
  • Southside Mobile Veterinary Services provides routine outpatient services in addition to basic, non-emergency medical care. If your pet is ill or injured and it is determined that they need more advanced/critical care, lab work, imaging (ultrasound or x-rays), general anesthesia or surgery (this includes spay/neuter or professional dental scaling & polish), then we will refer them to a nearby full-service facility. We do not provide mobile grooming services. If you need immediate assistance please call (770) 703-3324 or visit our Emergency & After Hours Care page for a list of the nearest recommended 24-hour Emergency Hospitals.

  • Primary Pet Information

    Please fill out each required field to the best of your knowledge.
  • Pet #1
    Name:   *   
    Species:      *   
    Breed:   *   
    Color/Markings:      
    Date of Birth/Age:   *   *  / Pick a Date  
    Sex:            *               
    Estimated Weight:      lbs.

  • Wellness Exam and/or Vaccination Information:

    Our Adult Annual Visit includes a full physical examination, recommended vaccinations based on exposure risk and current vaccination status, a blood test to screen for heartworms antigen (canine only) and check the organ systems for diseases, a fecal test to screen for intestinal parasites, along with broad-spectrum heartworm, intestinal worm, flea, and tick treatment and prevention. 

    Our Puppy/Kitten Packages include a brief physical examination, recommended vaccinations based on age, a blood test to screen for feline leukemia and feline immunodeficiency viruses (kitten only), a fecal to to screen for intestinal parasites along with broad-spectrum heartworm, intestinal worm, flea, and tick treatment and prevention. 

  • Additional Information (Wellness):
    Does your pet go to boarding and/or grooming?
       *   

    Will your pet be exposed to other animals or where other animals have been? (Examples include during neighborhood walks, dog parks, apartment complexes, wooded areas, lakes, etc.)
       *   
       
    Where does your pet spend most of its time?
             *   

    I would like heartworm prevention to prevent a serious and potentially fatal disease that affects the heart, lungs, and associated blood vessels, causing severe lung disease, heart failure and damage to other organs in the body.
       *     

    I would like flea & tick prevention to control infestations in my home, limit allergic skin reactions on my pet, and lessen the risk of serious disease transmission to myself or my family.
       *   

    I would like a bloodwork panel to screen for any early signs of infection or anemia as well as to assess the organs, tissues and metabolic state of my pet.
       *   

    I would like a microchip as a permanent ID for my pet that will also aid in recovery should my pet get lost or stolen.
          *   

  • In-Home Euthanasia Information:

    Gentle euthanasia includes a mild sedation to help alleviate any discomfort or anxiety prior to the procedure in addition to a paw print keepsake and information for a local pet loss support group.

    We partner with Deceased Pet Care for aftercare services. You have the option of private or communal cremation. With private cremation, your pet is cremated individually, and their ashes are returned to you. With communal cremation, your pet is cremated with other pets and their ashes are taken care of together by the crematory. If instead you would like to bury your pet at home, we recommend checking with your local ordinances for any restrictions as well as your local utilities for any gas or water lines buried underground.

  • Health Certificate Information:

    A certificate of veterinary inspection (CVI), also known as a health certificate, is an official document issued by a federal, state, tribal, or accredited veterinarian certifying that the animals identified on the document have been inspected and were found to satisfy the regulations pertaining to their intended movement – within the same state, between states, or internationally.

    Almost all airlines require a health certificate for travel, and some even have their own paperwork to fill out prior to even allowing you to check in or board the plane. Before deciding to travel with your pet, make sure to research on what requirements are necessary to ensure your pet does not get quarantined once you reach your destination or you may to incur any additional expenses for not following recommended guidelines.

    ​Please visit our section on Health Certificates for more information.

  • Information Needed for Health Certificate:

    Person traveling with your pet (along with contact information):
          
       
          
          
                   

    Departure Date:
    Pick a Date*   

    Arrival Date:   
    Pick a Date*   

    Destination state or country (including the specific address where the pet will be staying):
    *   
    *   *   *   *   *   *   
     

  • Additional Pet Information

    Please fill out each required field to the best of your knowledge.
  • Pet #2
    Name:   *   
    Species:      *   
    Breed:   *   
    Color/Markings:      
    Date of Birth/Age:   *   *  / Pick a Date  
    Sex:            *               
    Estimated Weight:      lbs.

  • Wellness Exam and/or Vaccination Information:

    Our Adult Annual Visit includes a comprehensive examination, recommended vaccinations based on exposure risk and current vaccination status, a heartworm antigen test (canine only), intestinal parasite screening, early disease screening (bloodwork), along with broad-spectrum heartworm, flea, and tick prevention. 

    Our Puppy/Kitten Packages include a brief physical examination, recommended vaccinations based on age, feline leukemia/feline immunodeficiency viral testing (kitten only), intestinal parasite screening and deworming, along with broad-spectrum heartworm, flea, and tick prevention. 

  • Additional Information (Wellness):
    Does your pet go to boarding and/or grooming?
       *   

    Will your pet be exposed to other animals or where other animals have been? (Examples include during neighborhood walks, dog parks, apartment complexes, wooded areas, lakes, etc.)
       *   
       
    Where does your pet spend most of its time?
             *   

    I would like heartworm prevention to prevent a serious and potentially fatal disease that affects the heart, lungs, and associated blood vessels, causing severe lung disease, heart failure and damage to other organs in the body.
       *     

    I would like flea & tick prevention to control infestations in my home, limit allergic skin reactions on my pet, and lessen the risk of serious disease transmission to myself or my family.
       *   

    I would like a bloodwork panel to screen for any early signs of infection or anemia as well as to assess the organs, tissues and metabolic state of my pet.
       *   

    I would like a microchip as a permanent ID for my pet that will also aid in recovery should my pet get lost or stolen.
          *   

  • Additional Pet Information

    Please fill out each required field to the best of your knowledge.
  • Pet #3
    Name:   *   
    Species:      *   
    Breed:   *   
    Color/Markings:      
    Date of Birth/Age:   *   *  / Pick a Date  
    Sex:            *               
    Estimated Weight:      lbs.

  • Wellness Exam and/or Vaccination Information:

    Our Adult Annual Visit includes a comprehensive examination, recommended vaccinations based on exposure risk and current vaccination status, a heartworm antigen test (canine only), intestinal parasite screening, early disease screening (bloodwork), along with broad-spectrum heartworm, flea, and tick prevention. 

    Our Puppy/Kitten Packages include a brief physical examination, recommended vaccinations based on age, feline leukemia/feline immunodeficiency viral testing (kitten only), intestinal parasite screening and deworming, along with broad-spectrum heartworm, flea, and tick prevention. 

  • Additional Information (Wellness):
    Does your pet go to boarding and/or grooming?
       *   

    Will your pet be exposed to other animals or where other animals have been? (Examples include during neighborhood walks, dog parks, apartment complexes, wooded areas, lakes, etc.)
       *   
       
    Where does your pet spend most of its time?
             *   

    I would like heartworm prevention to prevent a serious and potentially fatal disease that affects the heart, lungs, and associated blood vessels, causing severe lung disease, heart failure and damage to other organs in the body.
       *     

    I would like flea & tick prevention to control infestations in my home, limit allergic skin reactions on my pet, and lessen the risk of serious disease transmission to myself or my family.
       *   

    I would like a bloodwork panel to screen for any early signs of infection or anemia as well as to assess the organs, tissues and metabolic state of my pet.
       *   

    I would like a microchip as a permanent ID for my pet that will also aid in recovery should my pet get lost or stolen.
          *   

  • Additional Pet Information

    Please fill out each required field to the best of your knowledge.
  • Pet #4
    Name:   *   
    Species:      *   
    Breed:   *   
    Color/Markings:      
    Date of Birth/Age:   *   *  / Pick a Date  
    Sex:            *               
    Estimated Weight:      lbs.

  • Wellness Exam and/or Vaccination Information:

    Our Adult Annual Visit includes a comprehensive examination, recommended vaccinations based on exposure risk and current vaccination status, a heartworm antigen test (canine only), intestinal parasite screening, early disease screening (bloodwork), along with broad-spectrum heartworm, flea, and tick prevention. 

    Our Puppy/Kitten Packages include a brief physical examination, recommended vaccinations based on age, feline leukemia/feline immunodeficiency viral testing (kitten only), intestinal parasite screening and deworming, along with broad-spectrum heartworm, flea, and tick prevention. 

  • Additional Information (Wellness):
    Does your pet go to boarding and/or grooming?
       *   

    Will your pet be exposed to other animals or where other animals have been? (Examples include during neighborhood walks, dog parks, apartment complexes, wooded areas, lakes, etc.)
       *   
       
    Where does your pet spend most of its time?
             *   

    I would like heartworm prevention to prevent a serious and potentially fatal disease that affects the heart, lungs, and associated blood vessels, causing severe lung disease, heart failure and damage to other organs in the body.
       *     

    I would like flea & tick prevention to control infestations in my home, limit allergic skin reactions on my pet, and lessen the risk of serious disease transmission to myself or my family.
       *   

    I would like a bloodwork panel to screen for any early signs of infection or anemia as well as to assess the organs, tissues and metabolic state of my pet.
       *   

    I would like a microchip as a permanent ID for my pet that will also aid in recovery should my pet get lost or stolen.
          *   

  • Additional Pet Information

    Please fill out each required field to the best of your knowledge.
  • Pet #5
    Name:   *   
    Species:      *   
    Breed:   *   
    Color/Markings:      
    Date of Birth/Age:   *   *  / Pick a Date  
    Sex:            *               
    Estimated Weight:      lbs.

  • Wellness Exam and/or Vaccination Information:

    Our Adult Annual Visit includes a comprehensive examination, recommended vaccinations based on exposure risk and current vaccination status, a heartworm antigen test (canine only), intestinal parasite screening, early disease screening (bloodwork), along with broad-spectrum heartworm, flea, and tick prevention. 

    Our Puppy/Kitten Packages include a brief physical examination, recommended vaccinations based on age, feline leukemia/feline immunodeficiency viral testing (kitten only), intestinal parasite screening and deworming, along with broad-spectrum heartworm, flea, and tick prevention. 

  • Additional Information (Wellness):
    Does your pet go to boarding and/or grooming?
       *   

    Will your pet be exposed to other animals or where other animals have been? (Examples include during neighborhood walks, dog parks, apartment complexes, wooded areas, lakes, etc.)
       *   
       
    Where does your pet spend most of its time?
             *   

    I would like heartworm prevention to prevent a serious and potentially fatal disease that affects the heart, lungs, and associated blood vessels, causing severe lung disease, heart failure and damage to other organs in the body.
       *     

    I would like flea & tick prevention to control infestations in my home, limit allergic skin reactions on my pet, and lessen the risk of serious disease transmission to myself or my family.
       *   

    I would like a bloodwork panel to screen for any early signs of infection or anemia as well as to assess the organs, tissues and metabolic state of my pet.
       *   

    I would like a microchip as a permanent ID for my pet that will also aid in recovery should my pet get lost or stolen.
          *   

  • Additional Pet Information

    Please fill out each required field to the best of your knowledge.
  • Pet #6
    Name:   *   
    Species:      *   
    Breed:   *   
    Color/Markings:      
    Date of Birth/Age:   *   *  / Pick a Date  
    Sex:            *               
    Estimated Weight:      lbs.

  • Wellness Exam and/or Vaccination Information:

    Our Adult Annual Visit includes a comprehensive examination, recommended vaccinations based on exposure risk and current vaccination status, a heartworm antigen test (canine only), intestinal parasite screening, early disease screening (bloodwork), along with broad-spectrum heartworm, flea, and tick prevention. 

    Our Puppy/Kitten Packages include a brief physical examination, recommended vaccinations based on age, feline leukemia/feline immunodeficiency viral testing (kitten only), intestinal parasite screening and deworming, along with broad-spectrum heartworm, flea, and tick prevention. 

  • Additional Information (Wellness):
    Does your pet go to boarding and/or grooming?
       *   

    Will your pet be exposed to other animals or where other animals have been? (Examples include during neighborhood walks, dog parks, apartment complexes, wooded areas, lakes, etc.)
       *   
       
    Where does your pet spend most of its time?
             *   

    I would like heartworm prevention to prevent a serious and potentially fatal disease that affects the heart, lungs, and associated blood vessels, causing severe lung disease, heart failure and damage to other organs in the body.
       *     

    I would like flea & tick prevention to control infestations in my home, limit allergic skin reactions on my pet, and lessen the risk of serious disease transmission to myself or my family.
       *   

    I would like a bloodwork panel to screen for any early signs of infection or anemia as well as to assess the organs, tissues and metabolic state of my pet.
       *   

    I would like a microchip as a permanent ID for my pet that will also aid in recovery should my pet get lost or stolen.
          *   

  • Desired Date

    Select a desired date and timeframe for your appointment.
  • ***The options below are tentative dates and times and do not reflect current availability. Appointments are not confirmed until we have discussed the details of the services AND the pre-payment has been submitted.***

    For urgent requests (less than 48 hours), please call (770) 703-3324 to schedule.

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  • Acknowledgement and Signature

    By signing below, you certify that you are at least 18 years of age, are the owner or authorized agent of the pet(s) previously listed, you understand that payment is due at the time services are rendered, and that photos/videos may be taken of your pet(s) for training or marketing purposes.
  • Please read and check BOTH statements below, then type and sign your name in order to submit your appointment request.

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