SOUTHEAST GEORGIA VETERINARY CLINIC

104 CANDLER DR
BRUNSWICK, GA 31523

(912)554-8388

www.southeastgeorgiavetclinic.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

Name *(required)*

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Date of Birth :

How did you become aware of our clinic?

Sign
Internet
Yellow Pages

Contact Preference

Email
Text
Phone Call

Client Referral? If so who may we thank?

Other? If so where?

Payment Policy (Please read carefully)

(Please read carefully)
Payment is expected at the time services are rendered – No exceptions. We accept Checks ( with valid ID), MC, VISA, Discover, Care Credit and Cash. Please make sure you are able to provide one of these forms of payment before being seen by the Doctor or Staff. Any unpaid balance is subject to an additional 40% collection fee.

Initial (required)

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary Practice?

Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

MEDICAL RECORDS RELEASE FORM

In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, “a written authorization or other form of waiver executed by the client or an appropriate court order or subpoena” is required in order for us to provide a copy of your pet’s medical records

I certify that I am the owner of the patient (s) whose records are being requested, and by signing below, I hereby authorize Southeast Georgia Veterinary Clinic and Pawed Dog Hotel to release or obtain medical records on my pet(s) as deemed necessary. This shall cover all future requests.

Client Signature

Date :

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