Client Information

Name*

First

Last

Spouse's Name

Address*

Street Address

Address Line 2

City

State

ZIP Code

Driver's License #

Phone*

Email*

Referred By

Patient Information

Pet's Name*

Species*

Cat

Dog

Breed*

Color*

Sex*

Male

Neutered Male

Female

Spayed Female

Age*

Previous Vet

Medical Conditions/Allergies

Would you like to add a second pet?*

Yes

Patient #2 Information

Pet's Name*

Species*

Cat

Dog

Breed*

Color*

Sex*

Male

Neutered Male

Female

Spayed Female

Age*

Previous Vet

Medical Conditions/Allergies

Additional Information

Medical Records Release*

I authorize PCAC to release my pet’s records to any third party requesting them

I do not authorize PCAC to release my pet’s records without verbal permission

Social Media Release

I grant to Peachtree Corners Animal Clinic (PCAC) and its representatives and employees the right to take photographs of
me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Peachtree Corners
Animal Clinic may use such photographs of me and/or my pet with or without my name and for any lawful purpose,
including, for example, such purposes as publicity, illustration, advertising, and Web content.

Social Media Release Options*

PCAC may take photos of me and/or my pet

PCAC may NOT take photos of me and/or my pet

Payment Information

Our clinic accepts Cash, Visa, MasterCard, Discover, Care Credit, and Amex.

Read and Sign Below:

I understand that if my pet is seen by a doctor at any time, I will be charged an exam fee + any & all
services/products used. I understand all services/products are to be paid for in full at the time
services are rendered. I also understand that PCAC does not offer payment plans.

We do accept scratch
pay or care credit as forms of payments. As of 2022 we no longer accept checks as payment. All unresolved accounts will be reported to
the county as THEFT of SERVICES and will be sent to collections after 90 days and will incur a minimum charge of $12.25 for Phase I
collection, and a collection fee of 33% of the total amount due in additional fees for Phase II collections. I also will be held responsible for
all collection fees incurred, including court cost, attorney fees and any additional costs PCAC has to cover.

Name*

Date*

Signature*

Phone

This field is for validation purposes and should be left unchanged.

New Client Form

Client Information

Patient Information

Patient #2 Information

Additional Information