Ansley Animal Clinic

New Client Agreement


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 $65.00 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:




County for Rabies Registration:
E-mail:

Co-Owner
Name:
Primary Phone:

Animal Information – Please only include pet(s) we are seeing for your initial visit.
Name:
Species:
Breed:
Sex:
Color/Markings:
Is your pet microchipped?

Has your pet had any history of an allergic reaction to vaccines and/or medications? If so, please specify below:

Please upload any of your pet’s previous medical and vaccine history.
You may also e-mail previous history to info@ansleyanimalclinic.com.

If you are bringing a second pet to your initial visit, please complete their information below.
Name:
Species:
Breed:
Sex:
Color/Markings:
Is your pet microchipped?

Has your pet had any history of an allergic reaction to vaccines and/or medications? If so, please specify below:

Please upload any of your second pet’s previous medical and vaccine history.
You may also e-mail previous history to info@ansleyanimalclinic.com.

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 accept American Express, Visa, MasterCard, Discover
Name on card:
Last 4 digits on card:
Expiration Date:
Save card on file for future use?:

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 by phone.

Leave this empty:

Ansley Animal Clinic https://ansleyanimalclinic.com
Signature Certificate
Document name: New Client Agreement
Unique Document ID: ccfd5c26d025c6b6481999f9066e094dcba588d2
Timestamp Audit
April 1, 2020 3:36 pm EDTNew Client Agreement Uploaded by Ansley Animal Clinic - info@ansleyanimalclinic.com IP 96.80.59.201