New Client Form

Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To ensure the best care possible, please take the time to fill in this form completely. If you have any questions or are in need of immediate assistance, please contact us directly.

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Driver's License State *

Driver's License Number *

Driver's License Expiration Date *

Name on License *

First

Last

Who else is authorized to make decisions about your pet's healthcare?

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Please choose your location: *

Animal Clinic East
Animal Clinic Downtown

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Vaccination History (Date & Type of Last Vaccincations)

Please list any symptoms or problems that you have with your pet.

Please list any current medications.

Describe your pet's diet.

Please explain the reason for visit.

Financial Policy

Thank you for choosing Animal Clinic Inc. Our primary mission is to deliver the best and most comprehensive veterinary medical care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options.

Animal Clinic Inc. requires payment in full at the end of your pet's visit and/or at the time of discharge.

Payment Options
You can choose from:
- Cash, Electronic Check, Visa®, MasterCard®, American Express® or Discover Card®

- Convenient Monthly Payment Plans* from Care Credit®

• Allow you to begin treatment today and pay over time

• Available for any treatment amount

• Can be used repeatedly - for your entire family - without having to reapply*

- Scratch Pay®

• Scratch pay is not a credit card, but a one-time loan with simple repayment options.

• Apply right from your smart phone.

• No hidden fees, no prepayment penalty, no deferred interest.

*subject to credit approval

**For some treatments or hospitalized care, a deposit is required. Healthcare plans requiring comprehensive care of more than $500 or more, will require a 1 /2 deposit to begin your pet's treatment.

Additional Policy Information:
Animal Clinic Inc. charges $30.00 for returned checks.

For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier, however you are responsible for payment of service that day.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet. By signing this form, you agree to the foregoing terms of payment. *

I have read and understand.

By submitting this form, I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. *

I have read and understand.

Aggressive Animal Policy

Pets are sometimes presented to our hospital that are impossible to handle without exposing our staff and patients to unacceptable risk of injury. With an aggressive animal a satisfactory examination and proper treatment cannot be performed without reducing the quality of care that we can provide. For the safety of our patients, clients, and staff Animal Clinic Inc. will NOT provide services to animals that display unmanageable or aggressive behavior. The pet owner is responsible for any and all charges up to the time treatment is terminated. *

I have read and understand the Animal Clinic Inc. policy regarding aggressive animals.

Signature *

Please type your name.

Date *

Proudly serving the pets of Chattanooga, TN!

Animal Clinic East

1414 Gunbarrel Road, Chattanooga, TN 37421
Phone: (423) 894-8495 | Fax: (423) 894-0175

Hours of Operation
Monday - Friday: 7:00am - 6:00pm
Saturday - Sunday: Closed

Animal Clinic Downtown

2223 E. 23rd St, Chattanooga, TN 37407
Phone: (423) 698-2401 | Fax: (423) 698-3056

Hours of Operation
Monday - Friday: 7:00am - 6:00pm
Saturday & Sunday: Closed