New Client and Patient Information Form

Client Information
How Did You Find Out About Us? (Please check all that may apply).
Pet 1 information
Pet species
Pet 2 information
Pet species
Pet 3 information
Pet species

Please read the following carefully and then sign below indicating agreement. Without these consents, guarantees, and agreements, no pet may be admitted, checked-in, boarded, hospitalized, tested, treated, evaluated or left for pet grooming at this facility. We regret that we must insist on this. Thank you for your understanding.

I hereby consent to evaluation, testing, and treatment of my pet(s), including the dispensing and administration of medications and anesthetics along with other veterinary medical and surgical procedures, as may be determined to be necessary and desirable by my Chastain Veterinary Medical Group veterinarian, or those under his/her supervision.
I authorize Chastain Veterinary Medical Group at Meadow Brook Animal Hospital (MBAH) and/or Chastain Veterinary Medical Group at Preston Road Animal Hospital (PRAH) to acquire copies of any previous veterinary medical records which may exist elsewhere, and which pertain pets that I own. I understand that this information will be held in strictest confidence and is requested for internal use only, in order to maintain continuity of veterinary healthcare for my pet(s).
I grant the Chastain Veterinary Medical Group permission, at its discretion, to post my pet’s picture, brief story, and summary medical information on social media.
I understand that in order to help prevent the spread of infectious, contagious and communicable disease it is the policy of the Chastain Veterinary Medical Group that all dogs, cats, and ferrets, that are hospitalized, boarded, presented for grooming or admitted for any reason MUST BE CURRENT ON ALL STANDARD IMMUNIZATIONS AND FREE FROM INTERNAL AND EXTERNAL PARASITES. I understand that if my pet is admitted or checked in to the facility and my pet is not up to date on the community standard vaccinations, then he/she will be vaccinated as appropriate and/or treated for external parasites at the pet owner's expense, if the pet’s health status permits in the exercise of the judgment of the attending veterinarian.
I, the undersigned guarantor, assume financial responsibility for payment of all fees for services rendered to any and all of my pets by Chastain Veterinary Medical Group at Meadow Brook Animal Hospital and/or Chastain Veterinary Medical Group at Preston Road Animal Hospital. I understand that payment is due at the time services are rendered. I also understand that if the charges for my pets are not paid in full at the time services are rendered, my account could be subject to referral to a third party for collection with all reasonable collection fees becoming the responsibility of the undersigned guarantor. I understand that a returned check fee of $20.00 will be assessed for each non-sufficient funds check given to MBAH and/or PRAH.
Owner, Legal Representative or Owner's Authorized General Agent
Office Use
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