East Marietta Animal Hospital
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About
Pet Care Team
>
Dr. Diaz
Dr. Fugedy
Dr. Ferrall
Rena
Bobbi
Jenny
Jamie
Madison
Teresa
Jill
Juliett
Whitney
Contact
New Patients
Pet Services
Medical Services
Anesthesia and Patient Monitoring
Dental Health
Surgical Services
Wellness and Immunization Programs
Preventive Services
Nutritional Counseling
Boarding and Bathing
Additional Services
Forms/Request Services
Prescription and Product Refill Request
Welcome Form
Request Appointment
Request Boarding
Boarding Pre-Check In
Boarding Pre-Check In And Doctor Exam
Online Ordering
New Client Welcome Form
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Day-Time Phone Number
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Evening Phone Number
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Mobile Phone Number
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Email
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Co-owner's Name
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First
Last
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Co-owner's Phone Number
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How did you find out about our practice?
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Clinic Location
Personal Referral
Internet Search
Clinic Sign
Other
If a Personal Referral, please tell us who we can thank! Or if "Other" is chosen, please explain.
*
Please use this area to give us any other relevant information about yourself or your family
*
Pet's Information
Pet's Name
*
Species
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Canine
Feline
Breed
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Color
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SEx
*
Male
Neutered Male
Female
Spayed Female
Date of birth or Age
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Special identification (tattoo, microchip, etc.)
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Microchip Number
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Previous Veterinary Practice
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Previous Veterinarian
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Date of last vaccines (if known)
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What vaccines were given at this time
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Is your pet on any medications or supplements?
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Yes
No
What food does your pet eat?
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Are there any current or past medical conditions of which we should be aware?
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Yes
No
Please use the following box to give us any other relevant information about your pet
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MEDICAL AND VACCINE RECORDS
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Once we receive your pet's medical and vaccine history from a veterinarian, rescue, shelter or breeder, we will be able to make an appointment for your pet.
Please Choose One
*
I will forward my pet's medical and vaccine history via email to
[email protected]
I will fax my pet's medical and vaccine history to 770-973-1012
My pet was found as a stray and does not have previous medical or vaccine history.
My pet has not been to a veterinarian or vaccine clinic in many years and I do not have medical or vaccine history to provide. I am aware vaccines may be updated during its appointment.
Web and Social Media Release
East Marietta Animal Hospital has my permission to have my pet(s) photograph(s) posted on East Marietta Animal Hospital electronic media, including, but not limited to, promotional video, web pages, and social media such as Twitter, YouTube, and/or Facebook pages for the purpose of advertising.
Post Permission
*
OK to use pet/owner name
Keep Anonymous
I Decline Permission
Treatment Authorization Electronic Signature
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I understand payment in full is due at time of service and I assume responsibility for all charges incurred in the care of this animal.
Accepted forms of payment are cash, check (we do not accept counter or out of state checks), Care Credit, VISA, MasterCard, Discover or American express. There is a $30.00 fee for returned checks. A finance charge of $20.00 per month will be assessed on any portion of any unpaid balance. Also, I understand that a deposit may be required for treatment.
Signature
*
Submit
Home
See what our clients are saying about us!
About
Pet Care Team
>
Dr. Diaz
Dr. Fugedy
Dr. Ferrall
Rena
Bobbi
Jenny
Jamie
Madison
Teresa
Jill
Juliett
Whitney
Contact
New Patients
Pet Services
Medical Services
Anesthesia and Patient Monitoring
Dental Health
Surgical Services
Wellness and Immunization Programs
Preventive Services
Nutritional Counseling
Boarding and Bathing
Additional Services
Forms/Request Services
Prescription and Product Refill Request
Welcome Form
Request Appointment
Request Boarding
Boarding Pre-Check In
Boarding Pre-Check In And Doctor Exam
Online Ordering