New Client Form Scenic City Veterinary Services865 Rhea County Hwy Dayton, TN 37321 Phone: 423-661-2255 Briana Patten, DVM Sarah Wallace, DVMNew Client Form Thank you for giving us the opportunity to care for your pet (s). In order to maintain accurate records we ask that you complete all of the following information.Owner's Name First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneCell PhoneEmail I am aware that Scenic City Veterinary Services requires payment at the time of service. Itis NOT our policy to extend credit. If payment is not made and the account is turned over to our collection agency I agree to pay a 35% collection fee and reasonable attorney fees.Please indicate choice of payment: Cash Credit Credit/DebitSignaturePet’s NamePet 1Pet 2Pet 3 SpeciesPet 1Pet 2Pet 3 BreedPet 1Pet 2Pet 3 Date of BirthPet 1Pet 2Pet 3 ColorPet 1Pet 2Pet 3 SexPet 1Pet 2Pet 3 Spayed or NeuteredPet 1Pet 2Pet 3 Current WeightPet 1Pet 2Pet 3 Previous Vaccine reaction?Pet 1Pet 2Pet 3 Date of last Rabies Vaccination?Pet 1Pet 2Pet 3 Date of last DHPP (dogs) or FVRCP (cats)?Pet 1Pet 2Pet 3 Date of last Kennel Cough vaccine (dogs)?Pet 1Pet 2Pet 3 Date and type of any other known Vaccines (FeLV, Leptospirosis, Canine influenza, etc)?Pet 1Pet 2Pet 3 Current illness or known chronic conditions ?Pet 1Pet 2Pet 3 Previous serious illness or surgeries ?Pet 1Pet 2Pet 3 Current MedicationsPet 1Pet 2Pet 3 Vaccination Policy South Rhea Animal Hospital highly recommends core and required vaccinations to protect your pet from deadly diseases common in our area. Certain vaccinations are annual and others are every 2-3 years. These vaccinations will be tailored for each pet and their needs. Please discuss with your Veterinarian which of these vaccinations is appropriate for your pet. I understand vaccine reactions can occur but are rare. The benefits of vaccination outweigh the risks in majority of pets and most reactions are minor such as facial swelling and hives. These reactions should be reported in order to limit reactions in the future. I understand South Rhea Animal Hospital provides only safe and effective vaccinations that are species specific and stored appropriately. I also understand that qualified Veterinarians give appropriate “doses” of vaccines as recommended by the manufacturer. I consent/ do NOT consent to the Veterinarians at South Rhea Animal Hospital to vaccinate my pets and accept the potential risk of a vaccine reaction.I consent/ do NOT consent to the Veterinarians at South Rhea Animal Hospital to vaccinate my pets and accept the potential risk of a vaccine reaction. Consent Do NOT Consent I understand that Rabies vaccination is required by state law for all pets and must be kept current. I also understand that Tennessee State law requires a 1 year rabies booster before starting a 3 year protocol. I will provide Rabies vaccination proof and If I cannot provide proof South Rhea Animal Hospital will require a Rabies vaccination at my pet’s visit unless my pet has an illness, disease, or other special circumstance that would potentially make vaccinating risky. This protects South Rhea Animal Hospital’s employees, myself, and the public from a fatal disease that can be carried by Bats, skunks, foxes, raccoons, and coyotes. SignatureDate MM slash DD slash YYYY Consent*By providing my phone number, I consent to receive SMS text messages from Scenic City Veterinary Services for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg & data rates may apply. Reply HELP for support. Reply STOP to opt out. Refer to our "Privacy Policy" and "Terms and Conditions" for more information. I agree
