SAAC Client/Patient Info Form

Thank you for choosing South Athens Animal Clinic for your pet's needs. Please fill out our client/patient registration form to ensure we can provide you with the best possible care.
IMPORTANT:

Due to COVID-19, South Athens is only seeing curbside appointments. When you arrive for an appointment, please call from your vehicle. We will obtain the medical history and make arrangements with you to best meet you and your pets’ needs. Once this is arranged, we will come to your vehicle to greet your pet and bring your pet inside. The veterinarian will conduct your pet’s exam and perform approved services without you physically present. After the examination we will call you to discuss the examination and findings as usual, but with you remaining in your vehicle in the parking lot. Once services are completed, we will have you pay over the phone with a credit card and then we will bring your pet out to your vehicle.
Have you ever brought a pet to South Athens Animal Clinic before?*

YesNo
Owner's Name*

First NameLast Name
E-mail*
example@example.com
Main contact number:*
Is this your home, cell, work phone or other number?*

Home PhoneCell PhoneWork PhoneOther
Secondary contact number:
Is this your home, cell, work phone or other number?

Home PhoneCell PhoneWork PhoneOther
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Would You Prefer To Be Contacted?*

Phone (Main Number)Phone (Secondary Number)Text (Main Number)Text (Secondary Number)Email
Is there a spouse/partner/family member who should be listed on your account?*

YesNo
Spouse/partner/family member name

First NameLast Name
Please tell us how the above person is related to you so we can refer to your relationship appropriately.
E-mail
example@example.com
Spouse/partner/family member contact number:
Is this a home, cell, work phone or other number?

Home PhoneCell PhoneWork PhoneOther
How did you hear about us?

Google (or other search engine)FacebookSaw our hospital (location)Athens Area Humane SocietyA SAAC Team MemberA current SAAC clientOther
Please tell us who we may thank for your referral!
Do we have permission to take a photo of your pet while in the clinic, share their name, and post to our social media?*
Please type your Instagram handle if you would like to be tagged.
Pet's Name*
Upload A Picture of Your Pet

Cancelof
Species*

DogCat
Date of Birth/Age of your pet*
If date of birth is unknown, please tell us if age is listed in weeks, months or years.
Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?)*
Sex*

MaleNeutered MaleFemaleSpayed Female
Is your pet microchipped?*

YesNoI'm not sure
Microchip number (if known)
Would you like us to call your previous veterinarian to obtain medical records?

YesI will upload my pets previous recordsNo, please do not contact my previous veterinarian
Previous Veterinarian(s)
Upload previous veterinary records

Please upload if available.
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Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
We Love Social Media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, Twitter, www.poulsbomarinavet.com and any other marketing and/or other social media outlets we may choose to use? *

YesNo
I agree to release Poulsbo Marina Veterinary Clinic from all claims for libel, slander, invasion of privacy, infringement and copyright or right of publicity or any other claim and confirm that you are over the age of 18 years old. (initial below)*
Initial
South Athens Animal Clinic occasionally uses email and text for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email and/or text regarding these reminders?*

YesNo
Poulsbo Marina Veterinary Clinic no longer provides reminders for appointments or services due by mail. If you choose not to be contacted by email, text and/or our hospital app, we cannot guarantee timely reminders regarding your pet(s) health. If choosing not to provide permission to contact you digitally, please initial below indicating that you understand the above and release Poulsbo Marina Veterinary Clinic from any liability surrounding notification (timely or otherwise) regarding your pet(s) health care needs. *
Initial
FINANCIAL POLICY:

Our office accepts Visa, Mastercard, Discover, and American Express. We also accept cash and checks.

In addition, we also offer a 3rd party financing option for our clients via Care Credit. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Additionally, use of Care Credit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity.

As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer.

Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan upon request. Your signature below indicates your agreement with these policies.
Signature*

Clear
TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of the above listed pet and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of South Athens Animal Clinic to examine, prescribe for and treat my pet to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.
Signature*

Clear
Should be Empty:

IMPORTANT:

Client Policies and Procedures