New Client

HOURS:

Tuesday, Wednesday, & Thursday 9:00am to 5:00pm

AVSAC is a small animal dermatology, allergy, and skin referral clinic dedicated to identifying the cause for and treating chronic skin disease in dogs and cats. Once the diagnosis is made, our emphasis is on educating clients on optimal pet skin and coat care, thereby enhancing the lives of both pet owner and pet by significantly improving quality of life through improved skin and hair coat health.

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Atlanta Veterinary Skin & Allergy Clinic, PC

2293 Brockett Road
Tucker, GA 30084

(770)936-8922

www.atlantaskinvet.com

New Client Check In

If you would like to make an appointment, you can assist us by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client Information Sheet

Owner Name (required)

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

Text Area (required)

E-Mail Address (required) :

Co-Owner/ Spouse Name

First Name	Last Name

Phone
Phone Type	Phone Number

E-Mail Address :

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :

Breed: (required)

Sex: (required)

Male
Female

Neutered/Spayed (required) :

Medical records at General Practice? (required)

Yes
No

What is date of last Rabies Vaccine? (required)

Do you have pets medical records?

Name of General Veterinary Practice/ Address/ Phone number (required)

Text Block

May we request a copy of records? (required)

Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit? (required)

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Atlanta Veterinary Skin & Allergy Clinic, PC and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Atlanta Veterinary Skin & Allergy Clinic, PC's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and - (required)

I Agree
I Disagree

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Directions

HOURS:

Tuesday, Wednesday, & Thursday 9:00am to 5:00pm

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Atlanta Veterinary Skin & Allergy Clinic, PC - 2022

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