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New Client Information

*Please select which hospital location:

To establish an account you must be a legal adult 19 or older:

EXPRESS PRIOR CONSENT TO CONTACT CONSUMER BY CELL PHONE PER TCPA (TELEPHONE CONSUMER PROTECTION ACT):
You agree, in order for us to service your account or to collect monies you may owe, Goodwin Animal Hospital, and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.
I/We have read this disclosure and agree that Goodwin Animal Hospital, its employees and/or agents may contact me/us as described above.

FOR IDENTITY THEFT PURPOSES WE NEED TO SEE A COPY OF A VALID PHOTO ID. WE WANT TO TRY AND HELP STOP IDENTITY THEFT BY MAKING SURE THE PERSON WHO SIGNS AND AUTHORIZES SERVICES WITH US IS IN FACT THE ONE WHO SIGNS THIS PAPERWORK

If you have any additional person(s) that you will allow to bring in, pick up or make any medical decisions for your pet(s) in your behalf please list them below with a contact number.

If you have anyone that is NOT authorized to pick up and/or make any medical decisions regarding your pet(s) please list them below

OUR ACCOUNTING SYSTEM IS NOT SET UP TO INVOICE OUR CLIENTS. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. BY SIGNING BELOW, I AM STATING THE ABOVE INFORMATION IS TRUTHFUL AND CORRECT. SHOULD IT BECOME NECESSARY TO FORWARD THE ACCOUNT FOR COLLECTION, I AGREE TO BE RESPONSIBLE FOR ANY/ALL COLLECTION COSTS, SERVICE FEES, ATTORNEY FEES, AND/OR COURT COSTS WHICH WILL INCLUDE A 33.33% COLLECTION AGENCY FEE. I WAIVE NOW AND FOREVER MY RIGHT OF EXEMPTION UNDER THE LAWS OF THE CONSTITUTION OF THE STATE OF ALABAMA AND ANY OTHER STATE.

Any unpaid balance will be subject to a service charge of 1.5% per month, (18% APR). Late charges and additional service charges may also be added under certain conditions.

How did you first hear of our hospital?

TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, HOSPITALIZED AND BOARDING ANIMALS MUST BE CURRENT ON ALL VACCINES AND FREE OF INTERNAL AND EXTERNAL PARASITES. I AUTHORIZE THE DOCTOR TO PROVIDE VACCINES AND PARASITE CONTROL AS NEEDED FOR MY PET.

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.

Please initial here if you give your permission to allow us to publish photographs of your pet(s) on the internet via our webpage or any social media.

ANIMAL MEDICAL HISTORY

Pet #1

Pet #2

Pet #3

Pet's Name

Species (cat,dog,other)

Breed

Description (color)

Date of Birth

Age (years)

Sex

Length of time owned

Neutered/Spayed

Vitamins

Diet (kind of pet food)

Any known food allergies?

VACCINATIONS

Name of Former Clinic

Date of DHPP (distemper/parvo)

Date of Bordetella (dog)

Date of K-9 Influenza

Date of Rabies (dog/cat)

Date of Heartworm Test

Name of Heartworm Preventative

Date of FVRCP (infectious disease-cat)

Date of Feline Leukemia

Date of Feline Bordetella

Date of Fecal Exam (worms dog/cat)

Any vaccine reactions?

Prior Illness

Prior Surgery(s)

Dentistry

ATLANTA:

CHANTILLY:

Atlanta Hwy Location

Chantilly Pkwy Location

Atlanta Hwy Location

Chantilly Pkwy Location

Animal Hospital Hours

Atlanta Hwy Location

Monday:

7:00am - 6:00pm
Tuesday:

7:00am - 6:00pm
Wednesday:

7:00am - 6:00pm
Thursday:

7:00am - 6:00pm
Friday:

7:00am - 6:00pm
Saturday:

8:00am - 12:00pm
Sunday:

Closed

Chantilly Pkwy Location

Monday:

7:00am - 6:00pm
Tuesday:

7:00am - 6:00pm
Wednesday:

7:00am - 6:00pm
Thursday:

7:00am - 6:00pm
Friday:

7:00am - 5:30pm
Saturday:

8:00am - 12:00pm
Sunday:

Closed - Except Boarding Pickups 3-4 pm

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