Name: *

First

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone: *

Cell Phone:

Other:

Email: *

Spouse’s Name:

Spouse’s Cell Phone:

Is anyone other than yourself authorized to make medical decisions or approve treatments for your pet(s)? *

First

Last

Phone:

PET INFORMATION

Pet's Name: *

Breed: *

Color(s): *

Age/Date of Birth: *

Species (dog, cat, other.) *

Sex: *

Male
Female

Previously Spayed or Neutered? *

Yes
No

Obtained from: *

*For the safety of our staff, clients, and fellow patients, please alert us if your pet is fearful or aggressive so that we can take appropriate precautions.

Clinic Policy: Payment is due in full at the time services are rendered.

We accept cash, all major credit/debit cards, Scratch Pay and Care Credit.

We do not allow the charging of any services or products, nor do we accept checks

We will gladly prepare an estimate for you upon request for recommended procedures and treatments for your pet. Understand that an estimate is not an exact figure amount and additional testing and/or treatment may be needed. Please alert the receptionist prior to seeing the veterinarian with any concerns about being able to pay for services.

AUTHORIZATION

I hereby authorize the staff of Vidalia Veterinary Clinic (VVC) to provide medical care/treatment/surgery for all current and future pets on my account from this date forth. I agree to hold harmless VVC for any injuries incurred to or by my pet or myself while in the care of the clinic. I assume responsibility for all charges incurred and understand that those charges must be paid at the time of release. I also understand that a deposit may be required for treatments and services. I authorize Vidalia Veterinary Clinic (VVC) to take photos of my pet(s) during any visit to VVC and use for any purpose including but not limited to; record keeping, advertising, and web/social media content. *

I have read and accept the financial policy.

Date:

New Client Form

New Client Form

PET INFORMATION

Clinic Policy: Payment is due in full at the time services are rendered.

AUTHORIZATION

We’re excited to meet you!

Contact

Address

Hours

After Hours Emergency

Questions?

New Client Form

New Client Form

PET INFORMATION

Clinic Policy: Payment is due in full at the time services are rendered.

*AUTHORIZATION*

AUTHORIZATION