New Client Form

Animal Allergy & Dermatology Center of Central TX

2207 Lake Austin Boulevard
Austin, TX 78703

(512)477-4824

www.aadcaustin.com

Please complete and submit both the "New Client" and the "New Patient" forms immediately after making your appointment with AADC so Dr. Nichols may review these at the same time he is studying your pet's medical history. We must receive these forms a minimum of a week prior to your appointment. Upon successful submission, you will immediately see a confirmation message on your screen. If you do not receive this confirmation, your form was not successfully submitted, and you need to double check your form then resubmit. If we do not receive your forms at least one week prior to your appointment, you may be required to reschedule.Thank you.

Your Name (required)

First Name (required)	Last Name (required)

Co-Owner's Name

First Name	Last Name

Address
Street Address

City ,	State / Province	Zip / Postal Code

Phone
Phone Type	Phone Number

Phone
Phone Type	Phone Number

E-Mail Address :

Employer's Name and Address

Clinic Name of your General Practice Veterinarian

Name of your General Practice Veterinarian

Your Pet's Name

Choose one :

Breed

Color

Birth Date

Weight

Client Agreement - Please read the agreement in full by scrolling to the end of the text.

Animal Allergy and Dermatology Center (AADC) is exclusive to the treatment of skin and ear issues, and I understand I should consult with my General Practitioner for any other veterinary needs. I acknowledge that no guarantee can be made as to the results obtained from any medical treatment and assume financial responsibility for all charges incurred at AADC for the care of the above-named pet. I understand compensation for services performed by AADC must be paid in full in the form of cash, check, or credit card at the time service is provided, and AADC does not accept "Care Credit." Per the "Appointment Policy" on this website, I agree to provide a minimum of 24 hours notice (exception-by noon Friday for a Monday appointment) to cancel or reschedule an appointment and agree for my credit card to be charged the exam fee if I do not follow the appointment policy. I authorize AADC to store my credit card information on their secure system for medication refills, no show/cancellation fees, etc.

Please type your name below, which will serve as your electronic signature acknowleding you have read in full and agree to the above-stated policies. (required)

Date (required)

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Animal Allergy and Dermatology Center of Central Texas

Animal Allergy & Dermatology Center of Central TX

NEW CLIENT Form