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Memphis Animal Clinic Logo
Logo Memphis Animal Clinic
Memphis Animal Clinic
Schedule Your Appointment
901-617-4711
Memphis Animal Clinic Logo
Schedule Your Appointment
901-617-4711
    Memphis Animal Clinic Logo
  • Our Hospital
    • About
      Memphis Animal
      Clinic
    • Meet Our Team
    • Hospital Tour
    • Payment
      Solutions
    • Client Forms
    • Our Videos
  • Our Services
    • Preventive Care
    • Wellness Exams
    • Vaccinations
    • Puppy/Kitten And
      Senior Pet Care
    • Early Detection Testing
    • Parasite Prevention
      And Control
    • Nutritional Counseling
    • Pharmacy
    • Microchipping
    • General Medicine
    • Pet Allergies And
      Dermatology
    • Dental Care with Dental X-rays
    • Pain Management
    • Surgery
    • Pet Emergency Services
    • Specialty Vet Services
    • International Health Certificates
    • Pocket Pets
    • Boarding
    • Grooming
    • Wellness Plans
  • Client Forms
  • Resources
    • Blogs
    • News &
      Promotions
    • Pet
      Resources
    • FAQs
    • Wellness Plans
  • Home Delivery
  • Reviews
  • Contact

"Improving lives through personalized care. We treat you like family and each patient like our own pet."

"Improving lives through personalized care. We treat you like family and each patient like our own pet."

"Improving lives through personalized care. We treat you like family and each patient like our own pet."

New Patient/Consent Forms

If your pet is new to our office, the following link will allow you to access our new patient packet, which includes consent forms that must be filled out prior to your pet’s exam. For your convenience, you may download the forms here and print them out, which will allow us to attend to your pet’s medical needs more promptly.

  • NEW CLIENT CHECK-IN FORM

    Download
  • BOARDING CONSENT FORM

    Download
  • CANINE ASSESSMENT FORM

    Download
  • FELINE ASSESSMENT FORM

    Download
  • SURGICAL AND ANETHESIA CONSENT FORM

    Download

Should you have any questions or concerns while completing the forms, feel free to contact our office.

      New Client / Patient Form

      Thank you for choosing the Memphis Animal Clinic. We want to know our clients and patients. Please take a moment to fill out the information below. Thank you!

      Client Information

      *Required Fields

      *Owner's Name:

      *Spouse / Other:

      Address:

      City:

      State:

      Zip:

      Home #:

      Cell #:

      Available For Texting:

      Employer Name & Address:

      Referred By:

      Driver's License:

      SS #:

      Emergency Contact:

      *Email Address:

      Patient Information

      Pet's Name:

      Date of Birth:

      Breed:
      Color / Markings:

      Date of Neuter / Spay:

      Previous Medical Problems:

      Present Medications:

      Allergic To:

      Date of Last Vaccination:

      Given By:

      Payment is expected as services are rendered. The following methods of payment are accepted: Cash, Check, MasterCard, and Visa. A $25.00 service fee is assessed on all returned checks. A late charge is applied to all accounts unpaid after 30 days. Late charge is computed by a periodic rate of 1.50% per month, which is the annual percentage rate of 18.00%. Minimum charge is $2.00. If completed payment is not made, and collection of any portion of fees must be referred to an attorney for collection, the Client/Agent (Undersigned) agrees to pay reasonable court costs and attorney fees.

      Method of Payment:

      *Signature:

      *Date:

      Thank you for completing this form!
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      Boarding/Treatment Consent Form

      *Required Fields

      *Owners Name:

      Today's Date:

      *Pet's Name:

      Pick-Up Date:

      Reason for Visit (Choose all that apply):

      Is your pet?

      Is your pet eating?

      Last Meal?

      Is your pet drinking?

      Is your pet urinating?

      If your pet's stool (BM)?

      Is your pet experiencing any of the following?

      If other, please describe what your pet is experiencing

      Does your pet take any medications other than monthly preventions?

      Please list any medications

      Does your pet take insulin?

      Date/Time last administered?

      Please check/list any additional services you would like for your pet during their visit with Memphis Animal Clinic

      If other, please describe what service you would like for your pet

      1. All pets who are left at our facility MUST be up to date on the minimum vaccinations per the Memphis Animal Clinic policy. If vaccines cannot be verified, they will be administered at owner’s expense.

      2. All pets must be free of fleas and/or ticks. Any animal who presents with topical parasites will be treated accordingly and at the owner’s expense.

      3. Any pet that falls ill for any reason during their stay at Memphis Animal Clinic will be treated accordingly at the owner’s expense.

      4. Any pet that requires daily medication administration during their stay in our facility will incur an additional charge for this service.

      5. Memphis Animal Clinic will not be responsible for any personal items left during a pet’s stay. Owner will provide personal items at their own risk.

      6. The emergency contact listed, if not the pet owner, will act as the owner’s agent for any issues that may arise during a pet’s stay at Memphis Animal Clinic.

      I HAVE READ AND UNDERSTAND THE ABOVE. IF MY PET BECOMES SICK WHILE BOARDING I GIVE MEMPHIS ANIMAL CLINIC PERMISSION TO ADMINISTER THE NECESSARY TREATMENT AT MY EXPENSE.

      *Signature:

      *Date:

      Emergency Number:

      Name:

      Thank you for completing this form!
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      Canine Lifestyle Assessment Form

      * Pet Owner Name:

      Name of Dog:

      Breed:

      Date of Birth:

      Date of last preventive care visit:

      1. How many dogs live in your home?

      2. How many cats?

      3. Other pets in the household include:

      Travel and Outdoors

      4. How much time does your dog spend outside every day? (No. of Hours)

      5. Do you take your dog to any of the following (check all that apply):

      6. Do you travel with your dog?

      7. Do you take your dog hiking, hunting, camping, or fishing?

      Home Environment and Home Care

      8. Do you observe wild animals or other wildlife in your neighborhood?

      9. Do you or your dog visit homes where there are pets?

      10. Do other pets come to visit at your house?

      11. Does anyone with compromised immune systems live in or visit your home?

      12. Have you seen evidence of fleas, ticks or worms on any of your pets or in your home?

      13. Which pets do you treat for fleas, ticks, internal parasites, or heartworms?

      14. Please list all of the products, medications or supplements your dog is using,

      15. What kind of diet do you feed your dog?

      16. Do you feed your dog treats?

      17. What kind of exercise does your dog get?

      Unusual behavior

      18. Does your dog scratch, bite at its skin or seem “itchy”?

      19. Have you noticed

      Any weight loss or gain?
      Any change in your dog’s skin or hair coat?
      Any recent change in your dog’s behavior or activity level?
      Any signs of pain, like slow to get up or down, tremor or weakness in the rear legs, protecting of a certain body part?
      Any recent changes in your dog’s behavior when defecating or urinating?
      Thank you for completing this form!
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      Feline Lifestyle Assessment Form

      * Pet Owner Name:

      *Name of Cat:

      Breed:

      Date of Birth:

      Date of last preventive care visit:

      1. How many cats live in your home?

      2. How many dogs?

      3. Other pets in the household include:

      Travel and Outdoors

      4. How much time does your dog spend outside every day? (No. of Hours)

      5. Do you take your dog to any of the following (check all that apply):

      6. Do you travel with your cat?

      7. Do you take your cat on any outdoor activities?

      Home Environment and Home Care

      8. Do you observe wild animals or other wildlife in your neighborhood?

      9. Do you or your cat visit homes where there are pets?

      10. Do other pets come to visit at your house?

      11. Does anyone with compromised immune systems live in or visit your home?

      12. Have you seen evidence of fleas, ticks or worms on any of your pets or in your home?

      13. Have you noticed any fleas or ticks on your cat?

      14. Does your cat use the litter box, go outside, or both

      15. Please list all of the products, medications or supplements your dog is using,

      16. What kind of exercise does your cat get?

      17. What kind of diet do you feed your cat?

      18. Do you feed your cat treats?

      Unusual behavior

      18. Does your cat scratch, bite at its skin or seem “itchy”?

      19. Have you noticed

      Any weight loss or gain?
      Any change in your cat’s skin or hair coat?
      Any recent change in your cat’s behavior or activity level?
      Any signs of pain, like slow to get up or down, tremor or weakness in the rear legs, protecting of a certain body part?
      Any recent changes in your cat's behavior when defecating or urinating?
      Thank you for completing this form!
      You are missing required fields.
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      Surgical / Anesthesia Consent Form

      *Required Fields

      *Owners Name:

      *Contact phone#

      *Pet's Name:

      I am the owner or agent for the above-described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s):

      I understand that during the performance of the foregoing procedures, unseen conditions may be revealed that may necessitate additional treatment. I authorize such treatment and procedures as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I also release Memphis Animal Clinic from any liability concerning this procedure. I have been advised as to the risks involved in this procedure and that the results cannot be guaranteed.

      IF FLEAS ARE SEEN ON YOUR PET WE RESERVE THE RIGHT TO PROTECT OTHER PATIENTS IN OUR FACILITY. IF FLEAS ARE NOTICED WE WILL APPLY THE NECESSARY FLEA PREVENTION TO YOUR PET AND IT WILL BE ADDED TO THE TOTAL COST OF THE BILL.

      Pre-Anesthetic Blood Testing
      We would like to inform you as the owner of this animal that hidden medical problems may manifest themselves by the stress of surgery. These medical problems may not always be obvious to the owner or the veterinarian. We advise a minimum database of presurgical blood work to ensure the safest anesthetic procedure possible for your pet. The cost is $49.95 for testing performed at the clinic immediately prior to anesthesia. These include hematocrit, total protein, BUN, ALT, CREA, and blood glucose.

      More thorough blood and urine tests are highly recommended for geriatric or chronically ill patients. These tests can be performed by an outside laboratory. It will take one additional day for these tests to be performed. Your pet’s elective surgery can be rescheduled if you decide that you too would like to be as safe as possible and have these tests performed. The additional charges for these tests would be $ 104.95. If you would like these additional tests, discuss your decision with the doctor.

      Intravenous Fluids
      Intravenous fluids given during anesthesia and/or surgery help to maintain blood pressure and allow rapid administration of drugs should an emergency situation develop. If blood pressure drops during the anesthesia it is more difficult to then place an IV catheter and valuable time may be lost which can result in the death of your pet. In the case of geriatric or chronically ill patients, catheter placement and fluids will be required and you will be informed of this prior to surgery

      Microchipping Service:
      Microchips are used as a permanent ID for your pet. If your pet were to ever get lost this would aid in their return home. We use the Home Again microchip system and while your pet is under anesthesia is an ideal time to place it. The microchip costs $49.95 with registration if they are under anesthesia. Additional registration fees apply through Home Again. Please initial if you would like us to place this today.

      E-Collar Consent:
      It is hospital policy that all pets with an incision are discharged with an e-collar to protect the pet from chewing or licking the surgical site. Serious complications (i.e. dehiscence) may arise if a pet licks or chews apart an incision. We are able to provide your pet with an e-collar upon discharge and it will be yours to keep.

      Post-Surgical Consent:
      We would like to inform you that there may be some degree of pain involved in this surgical procedure. We recommend that your pet receive an injection for the pain.

      YES, I want my pet medicated for post-surgical pain. The cost is $34.95 to $38.95 depending on the animal’s weight.
      YES, I want my DOG to receive pain medication for home. The cost is $16.95 to $24.95 depending on the DOG’S weight.
      YES, I want my CAT to receive pain medication for home. The cost is $9.95 to $19.95 depending on the need for home meds as determined by the veterinarian. Kidney enzymes may be required to check at $19.95.
      NO, I decline this service for my pet.
      In Case of Emergency
      Emergency telephone number where I may be reached:

      ​​​​​​​I authorize the doctor, his/her agents or staff in an emergency situation to follow through with such procedures as are necessary for the well being of my pet on a continuing basis regardless of the additional cost which I understand cannot be estimated or calculated at this time. I understand that I assume all financial responsibility for all services rendered and for the cost of any inventory utilized during this emergency procedure.
      I DECLINE any emergency treatment if complications develop during the above procedure.
      It is understood that if any estimate is given to the owner/agent by the doctor, his/her agents, servants, and/or representatives to the owner/agent of owner that this is only an estimated price for the service rendered. It is understood that there may be unforeseen complications and that further treatment may be necessary for your pet during or following the above described surgical procedure.

      The owner/agent of owner acknowledges, accepts and assumes full and total financial responsibility for any and all services rendered by Memphis Animal Clinic, its staff or employees in the treatment of the above described animal and to pay for such services when the services are performed or when the animal is picked up.

      *Signature:

      *Date:

      I have read and received the Post-Surgical Discharge instructions.

      *Signature:

      *Date:

      Thank you for completing this form!
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      Contact Information

      • Address
        733 East Parkway South Cooper-Young/Midtown Memphis, TN 38104
      • Phone
        901-617-4711
      • Email
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      Memphis Animal Clinic

      Animal Hospital Hours

      • Monday:
        7:30am - 6:00pm
      • Tuesday:
        7:30am - 6:00pm
      • Wednesday:
        7:30am - 6:00pm
      • Thursday:
        7:30am - 6:00pm
      • Friday:
        7:30am - 6:00pm
      • Saturday:
        7:30am - 12:00pm
      • Sunday:
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