New Client & Patient History Forms | Atlanta Veterinary Eye Clinic

Section 1 of 4

Owner / Client Information

Full Name * Please enter your full name.

Street Address * Please enter your address.

City * Required.

State

Zip Code

Email Address * Please enter a valid email address.

Cell Phone * Please enter a phone number.

Home Phone

Work Phone

Section 2 of 4

Patient / Pet Information

Pet's Name * Please enter your pet's name.

Species *

Breed

Coat Color

Weight (lbs)

Date of Birth / Age

Sex

Male Female

Altered Status

Intact Spay / Neutered

Temperament

Good Nervous Will Bite

Section 3 of 4

How Did You Hear About Us?

Referring Veterinarian (name)

Regular Veterinarian

Friend (name)

Groomer (name)

Internet / Website (how did you find us?)

AVEC Cancellation Policy

Atlanta Veterinary Eye Clinic specializes in veterinary ophthalmology (diseases and surgery of the eye). Diagnosis and treatment of ocular disease in all animal species is provided.

Fees are payable when services are rendered. Payment can be made in cash, check, Master Card, or Visa.

A cancellation or request to reschedule less than 24 hours in advance of your appointment will invoke a cancellation fee of 50% ($110.00) of the booked services.

Should you arrive more than 15 minutes late for your appointment, we cannot guarantee that we will provide the service. If we cannot accommodate you, the same cancellation fee will be charged.

A credit card is required to make an appointment. Cancellation fees will be charged to the card you provide.

Section 4 of 4 — Page 1

Owner / Agent Signature & Acknowledgement

Please type your full name and check the box below to acknowledge the AVEC Cancellation Policy and confirm the accuracy of your information.

Today's Date * Please enter today's date.

Full Name (typed signature) * Please type your full name to sign.

I have read and agree to the AVEC Cancellation Policy above. I confirm that all information I have provided is accurate to the best of my knowledge.

Please check the box to confirm your agreement.

New Client & Patient Intake Forms

AVEC Cancellation Policy

Forms Received — Thank You!