Ansley Animal Clinic

New Client Form


Thank you for choosing us to care for your pet(s). We look forward to your upcoming appointment. At Ansley Animal Clinic we recognize that everyone's time is valuable. Our appointment times are limited, so we ask that you provide a 24-hour notice if you are unable to keep your appointment. Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, we require a credit card for all new client appointments. A $75.00 fee will be charged only if you miss your appointment or cancel with less than 24 hours' notice. Please sign this form as soon as possible so we can create your account. 

Primary Owner/Contact:   
Name:    Primary Phone:  
Address:        
Rabies vaccine registration  

Co-Owner Name 
Primary Phone  


Your last Veterinary Hospital
What is the name and location of your previous veterinary hospital? 


Pet Information
Name: Species: Sex:
Is your pet spayed or neutered?

Breed:    Color/Markings:   Is your pet microchipped?
Date of Birth (approx)
Does this pet have a history of allergic reactions to vaccines and/or medications?
 


Additional Pet - Please only include pet(s) we are seeing for your initial visit.
Name:  Species:      Sex:
Is your pet spayed or neutered?

 
Breed: Color/Markings:   Is this pet microchipped? 
Date of birth:
Does this pet have a history of allergic reactions to vaccines and/or medications?
 


Referrals
At Ansley Animal Clinic, referrals are the highest compliment you can give us. If a friend referred you to us, please list their name so that we can thank them by adding a credit to their account.  

Photo Release 
I authorize Ansley Animal Clinic to photograph me and/or my pet(s) and give my consent to use those photographs in any and all publications, educational materials, research, advertising, news media, and social media/internet materials.

 


Credit Card Authorization 
We collect payment information prior to appointments as a deposit.  Please provide the card type, last 4 digits, and expiration date. We accept American Express, Visa, MasterCard, Discover. A receptionist will contact you before your appointment to complete the information. 

  Name on card:   Last 4 digits  
Expiration   Keep card on file?  

IMPORTANT: Professional fees are to be paid at the time services are rendered. We accept all major credit cards, check/debit cards, cash, and personal checks with the proper identification. By signing below, you acknowledge that you have received this notice, understand this policy, and authorize us to charge the credit card that you provided.

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Signature Certificate
Document name: New Client Form
lock iconUnique Document ID: c77aa4264e121f01a31ee42a30ee059966436407
Timestamp Audit
April 19, 2023 5:10 pm ESTNew Client Form Uploaded by Ansley Animal Clinic - info@ansleyanimalclinic.com IP 136.41.128.70