Cohutta ANIMAL CLINIC
(706)946-7387
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FORMS
New Patient Form
Request A Refill
Home
About
Our Team
Our Services
Wildlife Triage
KANGEN WATER
FAQ
GENERAL FAQ
Emergency FAQ
FLEAS/HEARTWORM FAQ
Payment/Refund FAQ
Helpful Links
Contact
FORMS
New Patient Form
Request A Refill
NEW PATIENT FORM
*
Indicates required field
Pet Owner's Name
*
First
Last
Home Phone Number
*
Cell Phone Number
*
Spouse's Name
*
First
Last
Work Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Who may we thank for you Referral?
*
Choose One
*
Male
Female
Neutered Male
Spayed Female
Breed
*
Color &/or Markings
*
Pet's Name
*
Species
*
Dog
Cat
Bird
Rabbit
Reptile
Ferret
Llama
Other
Pet's Age
*
Pet's Birthday
*
Reason for visit
*
Previous Vet
*
Previous Vet's Phone Number
*
By clicking
SUBMIT
below, I am authorizing the veterinarian to examine, prescribe for and treat the above-described pet. I assume full responsibility for the 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 extensive treatment. Furthermore, in accordance with the Georgia Veterinary Practice Act regarding the confidentiality of patient medical records, I authorize the release of my pet's vaccination and other medical records by Cohutta Animal Clinic as my pet's circumstances warrant to the following: Boarding kennel, Groomer, Veterinary Specialty (Referral) Practices, or Other Veterinary Clinics.
Submit
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