New Patient Checklist Δ Owner Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone Number*Employer*Spouse/Co-owner name First Last PhoneEmail How did you hear about the clinic ?Emergency ContactPlease provide us with the name and phone number of the person you would like us to contact in case of an emergency.Name* First Last Phone*Payment PolicyI am aware that all fees and charges are due at the time of release of the patient. GVH accepts cash, debit, Visa, MasterCard, American Express, and Discover. Any balance forward is subject to finance charges. If my open account is in default, I agree to pay all costs of collections, court and attorney fees. Signature of Owner*Date* MM slash DD slash YYYY PATIENT INFORMATIONPet Name*CatPlease Select Your Breed Domestic Shorthair Domestic Longhair Other DogBreedColorSex* Male Neutered Male Female Spayed Female Date of Birth or Age*Where did you acquire pet? Shelter/Rescue Breeder Other How long have you had pet?*List any significant health issues ?*Is there any history of vaccine reactions?* Yes No If yes, to which vaccine?Name of previous veterinarian (for vaccine history)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What Heartworm / Flea prevention do you use?When was it last given?*TREATMENT AUTHORIZATIONI hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet.Signature of Owner*Date* MM slash DD slash YYYY VCPR POLICY & NOTICE OF MEDICAL RECORD RELEASEVeterinary-Client/Patient Relationship (VCPR) In accordance with the principals of veterinary medical ethics as directed by the American Veterinary Medical Association (AVMA), the VCPR is the basis for interaction among veterinarians, their clients and their patients. The VCPR exists when the veterinarian assumes responsibility for making clinical judgments regarding the health of the animal and has sufficient knowledge of the animal(s) to initiate treatment. To maintain a VCPR, a thorough examination of the patient must be performed within one year of any treatments or medication administered or prescribed. In accordance with the FDA Compliance Policy Guideline 7132.09 and Health and Safety Code Section 11400, we cannot return prescription items. Once these items have left the hospital we no longer have the assurance of the strength, quality, purity or identity of the articles and it is considered dangerous to return these items to shelf stock.SignatureDate* MM slash DD slash YYYY Medical Record Release It has always been this hospital’s goal to show the utmost respect for our clients and patients. We take the medical records of your pet very seriously, following the strict guidelines set forth by the American Veterinary Medical Association (AVMA) and the Georgia Veterinary Medical Association (GVMA). We work to keep your records complete with detailed entries of the services and procedures administered to your pet, as well as entering notations, observations and findings during your visit, and during client communications. It is our goal to maintain confidentiality and respect your privacy. In order to comply with the current standards directing the release of veterinary patient medical records, we must have your written consent to transfer, copy or transmit either a portion of or the entire medical history for your pet, from our hospital. Consent for the Release of Medical Records (Please Select One)Name First Last Please Select* I authorize Georgetown Veterinary Hospital to release/disclose my pet’s health and medical records to any veterinary, grooming, boarding, or pet care facility that may request them. I do not authorize Georgetown Veterinary Hospital to release/disclose my pet’s health and medical records without prior consent written & verbal consent. Declaration*Client's Name*Pet's Name*Client's Signature*Date* DD slash MM slash YYYY