New Pet Intake Form

Guardian Information

Please provide the information below as completely as possible. All information is strictly confidential.

Partner/Spouse Name

Mailing Address

Pet Information

Referral

Medical History

Statement of Ownership

I certify I am the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed.  I hereby agree to pay all amounts and charges after incurred by members of my family for services rendered by this hospital.

Failure to make payments in full at the time of those services are performed, or when requested, is basis for legal action.  I agree to pay all cost of collection including a reasonable fee, and hereby waive my rights of exemption under the law of the state of Georgia and any other state.

Release to Use Photograph

I authorize CMAH to edit, alter, copy, exhibit, publish or distribute photos of my pet for purposes of publicizing CMAH's programs or for any other related lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

I hereby hold harmless and release and forever discharge CMAH from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.