NEW CLIENT FORM

Welcome to Sea Island Animal Hospital!

Thank you for allowing us to care for your pet. Please fill out this form as completely as you can. If you have any questions, you can call (843) 524-4551 and we will be glad to help you!
Owner Full Name*

First NameLast Name
Spouse Name/ 2nd owner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Email Address:*
example@example.com
Secondary Phone Number
Please enter a valid phone number.
DRIVER'S LICENSE NO:*
DRIVER'S LICENSE STATE:*
Emergency Contact*
Please enter a valid phone number.
Employer:*
Are you a senior, Military member (active or retired) or a first responder?
How did you hear about us?*
PATIENT/PET INFORMATION
PET'S NAME:*
What type of pet?*

DogCatOther
What sex is your pet?*

MaleMale NeuteredFemaleFemale Spayed
What is your pet's birthday (may approximate)?*

MonthDayYear
Date
What breed is your pet?*
What color is your pet?*
Date & Type of Last Vaccines:
Please bring copy of vaccine records or attach below
Please upload any previous medical record history (files, pictures, videos, etc).

Cancelof
Type of Diet Fed?
Current Medications:
Current Heartworm Prevention
Current Flea prevention
Allergies or special instructions
AUTHORIZATION
We will gladly prepare a written estimate of service fees if you desire. All professional fees are due at the time services are rendered. We accept cash, check and major credit cards. In case of extensive medical or surgical procedures, we may require a deposit. We offer Care Credit financing for qualified clients. Please ask a receptionist for details. Returned checks are subject to a $30 returned check fee. All balances are subject to a monthly finance charge.

I hereby authorize the veterinarian to examine, prescribe for, or treat my pet(s I assume full financial responsibility for all charges incurred in the care of my animal(s). I also understand that payment is due when services are rendered.
Owner Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Welcome to Sea Island Animal Hospital!

PATIENT/PET INFORMATION

AUTHORIZATION