Highland Mobile Veterinary Service

P.O. Box 8066
Atlanta, GA 31106

(404)660-1271

www.highlandmobilevet.com

New Client/Patient Check In

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

Thank you for your cooperation in letting us assist you.

New Client/Patient

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
County (required)

Primary Phone (required)
Phone TypePhone Number (required)
Seconday Phone
Phone TypePhone Number
E-Mail Address :
Pet's Name (required)

Species: (required)

Canine
Feline


Breed: (required)

Color: (required)

Birthday (estimate OK) (required)

Neutered/Spayed (required)

Yes
No


Sex: (required)

Male
Female


Weight (Estimate OK) (required)

Are your pets vaccines current?

Yes
No


Do you have a copy of your pet's medical records?

Yes
No


Reasons or conditions that prompted your inquiry.

Additional Comments (Include list of any additional pets)

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 Highland Mobile Veterinary Service 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 Highland Mobile Veterinary Service'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 -

I Agree
I Disagree



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