New Client/Patient Form

New Client/Patient Form

South Rhea Animal Hospital | 865 Rhea County Hwy | Dayton, TN 37321
Thank you for giving us the opportunity to care for your pet(s). In order to maintain accurate records, we ask that you complete all of the following information.
Your Name*

First NameLast Name
Your Driver's License #: Enter Driver's License Number*
Spouse's Name

First NameLast Name
ALTERNATE EMERGENCY CONTACT:
Name: Name of emergency contact person
Relation: How is this person related?
Phone: Emergency contact's phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Your Employer: Enter employer name*
Work Phone: Enter work phone*

Spouse's Employer: Spouse emploer
Spouse's Work Phone: Spouse work phone
I am aware that South Rhea Animal Hospital requires payment at the time of service. It is not our policy to extend credit. If payment is not made and the account is turned over to our collection agency, I agree to pay a 35% collection fee and reasonable attorney’s fees. Please indicate choice of payment:

Initial for cash payment Cash
Initial for credit payment Credit
Initial for Credit / Debit payment Credit / Debit
Signature*

Clear
How did you find out about us?

Drove byWebsiteFriend / FamilyFacebook
Personal recommendation. Whom may we thank? Name of person who recommended us.
I understand South Rhea Animal Hospital is not a 24-hour emergency facility, therefore, referrals to local emergency centers may be recommended if overnight or intensive care is needed.

PET'S NAME:
Pet 1: Pet 1 name
Pet 2: Pet 2 name
Pet 3: Pet 3 name

SPECIES:
Pet 1: Pet 1 species
Pet 2: Pet 2 species
Pet 3: Pet 3 species

BREED:
Pet 1: Pet 1 breed
Pet 2: Pet 2 breed
Pet 3: Pet 3 breed

DATE OF BIRTH:
Pet 1: Pet 1 DOB
Pet 2: Pet 2 DOB
Pet 3: Pet 3 DOB

COLOR:
Pet 1: Pet 1 color
Pet 2: Pet 2 color
Pet 3: Pet 3 color

SEX:
Pet 1:
Pet 2:
Pet 3:

SPAYED OR NEUTERED:
Pet 1:
Pet 2:
Pet 3:

WEIGHT:
Pet 1: Pet 1 weight
Pet 2: Pet 2 weight
Pet 3: Pet 3 weight

PREVIOUS VACCINE REACTION?:
Pet 1:
Pet 2:
Pet 3:

DATE OF LAST RABIES VACCINATION:
Pet 1: Pet 1 last rabies vaccine date
Pet 2: Pet 2 last rabies vaccine date
Pet 3: Pet 3 last rabies vaccine date

DATE OF LAST DHPP (dogs) or FVRCP (cats):
Pet 1: Pet 1 last DHPP / FVRCP date
Pet 2:Pet 2 last DHPP / FVRCP date
Pet 3:Pet 3 last DHPP / FVRCP date

DATE OF LAST KENNEL COUGH VACCINE:
Pet 1:Pet 1 last kennel cough vaccine date
Pet 2:Pet 2 last kennel cough vaccine date
Pet 3:Pet 3 last kennel cough vaccine date

DATE AND TYPE OF ANY OTHER KNOWN VACCINES? (FeLV, Leptospirosis, Canine influenza, etc.):
Pet 1:Pet 1 other vaccine(s)
Pet 2:Pet 2 other vaccine(s)
Pet 3:Pet 3 other vaccine(s)

CURRENT ILLNESS OR KNOWN CHRONIC CONDITION(S)?:
Pet 1: Pet 1 illness / condition
Pet 2: Pet 2 illness / condition
Pet 3: Pet 3 illness / condition

PREVIOUS ILLNESS OR SURGERIES?:
Pet 1: Pet 1 illness / surgeries
Pet 2: Pet 2 illness / surgeries
Pet 3: Pet 3 illness / surgeries

CURRENT MEDICATIONS:
Pet 1:Pet 1 medications
Pet 2:Pet 2 medications
Pet 3:Pet 3 medications

Initial   I give South Rhea Animal Hospital permission to call or email to obtain records for my pet(s) from previous clinics.

Initial   I give South Rhea Animal Hospital permission to send medical records for my pet(s) to another Vet clinic that may request them.

VACCINATION POLICYSouth Rhea Animal Hospital highly recommends core and required vaccines to protect your pet from deadly diseases common in our area. Certain vaccinations are annual and others are every 2-3 years. These vaccinations will be tailored for each pet and their needs. Please discuss this with your Veterinarian which of these vaccinations is appropriate for your pet.

Initial* I understand vaccine reactions can occur, but are rare. The benefits of vaccination outweigh the risks in the majority of pets and most reactions are minor such as facial swelling and hives. These reactions should be reported in order to limit reactions in the future. I understand South Rhea Animal Hospital provides only safe and effective vaccinations that are species-specific and stored appropriately. I also understand that qualified Veterinarians give appropriate “doses” of vaccines as recommended by the manufacturer.

Initial* I understand that rabies vaccination is required by State law for all pets and must be kept current. I also understand that Tennessee State law requires a 1-year Rabies booster before starting a three-year protocol. I will provide Rabies vaccination proof and if I cannot provide proof, South Rhea Animal Hospital will require a Rabies vaccination at my pet’s visit unless my pet has an illness, disease, or other special circumstance that would potentially make vaccinating risky. This protects South Rhea Animal Hospital's employees, myself, and the public from a fatal disease that can be carried by bats, skunks, foxes, raccoons, and coyotes.

* to the Veterinarians at South Rhea Animal Hospital to vaccinate my pet(s) and accept the potential risk of a vaccine reaction.
Signature*

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