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Download New Client Form - Animal Dermatology Clinics
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New Client Form Contact Information Primary Veterinarian Client: Chris Walker Address: 798 Virginia Ave SE, Atlanta, Georgia 30306-3669 Name: . . Clinic: Ansley Animal Clinic Address: 593 Dutch Valley Road Atlanta , GA 30306 Home/Primary Phone: 248-444-8904 Mobile Phone: Work Phone: Email: [email protected] Drivers License #: 056931783 Employer Moxie 384 Northyards Blvd Atlanta, GA 30313 Phone: 404-873-1786 Email: Pet Information Pet's Name: Blu Species: canine Gender: male Spayed?: spayed Breed: Golden Retriever Color: Golden Birthdate: 12/01/2003 Weight: 95 (lbs.) Referral Information Clinic Selected Referral Source: Primary Veterinarian Referral Details: Animal Dermatology Clinic 1453 Terrell Mill Rd SE, Suite 119 Marietta, Georgia 30067 Phone: (770) 422-2509 Fax: (770) 422-8750 Email: [email protected] Signature Required The Animal Dermatology Clinic specializes in the treatment of allergies, ears, and skin disease only. If your pet has any other medical or surgical needs you should consult with your primary care veterinarian. If your pet is hospitalized overnight he/she will be under the care of the emergency clinic located in our facility, and charges may be incurred. All fees are due upon release of your pet. Any medications, antigens, or other medical supplies mailed to you will be billed separately and in addition to appointment charges. We accept cash, personal checks, Mastercard, Visa, and Discover. We are leaders and teachers in the field of veterinary dermatology. Medical files, thus case information and/or photos and videos may be used in teaching, forms, continuing education, promotional purposes, website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; client confidentiality (names and personal information) will be maintained. I understand that no guarantee can be made as to the results obtained from medical treatment. Further, I assume financial responsibility for all charges incurred by the patient. __________________________________________________________ Signature of Owner or Responsible Agent Date______________ Please bring, email or fax this document to the clinic selected.
