SAAC Client/Patient Info Form

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)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?

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

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.

We Love Social Media! Do we have your permission to post pictures of your pet(s) and share their name on Facebook, Instagram, and/or other social media outlets we may choose to use?*

YesNo

South Athens Animal Clinic occasionally uses email and text for communications regarding our patients' reminders for health care needs. Do we have your permission to contact you via email and/or text regarding these reminders? Your phone number will not be shared with third parties for marketing or promotional purposes.* I agree to receive text messages from South Athens Animal Clinic regarding account notifications and reminders for health care needs at the phone number I provided. I understand that my consent to be contacted is not a requirement to purchase any product or service. Message & data rates may apply. Message frequency varies. I can opt out at any time by replying STOP or HELP for assistance. I agree to the Terms of Service and Privacy Policy.*

YesNo

Below you will find South Athens Animal Clinic's Privacy Policy, which is also available on our website's Contact page.

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*

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*

Client Policies and Procedures