NEW CLIENT FORM
 
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please fully complete the following:
 
CLIENT INFORMATION                                                                 Date ______________________
 
Name ________________________________ Spouse’s Name ____________________________________
 
Physical Address (P.O. Box is unacceptable) __________________________________________________
 
City ___________________  in county or city of _________________    State______ Zip_______________
 
Phone________________Work Phone ___________________ Spouse’s Work Phone _________________
 
Place of Employment ______________________________ Best Time To Reach _____________________
 
Driver’s License # ___________________________        E-Mail Address ___________________________
 
I am the owner or agent of the owner of the presented animal(s) and have the authority and am legally able to execute this consent. I hereby consent and authorize the performance of the procedures as explained to me. ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Accounts remaining unpaid will incur interest at the rate of 18% per annum (1.5%/month) plus $5.00 per month billing fee. Late payments are subject to a late fee of $10.00. We reserve the right to require immediate and full payment on all overdue accounts. There will be a fee of $50.00 on all retuned checks. Any check returned to us for insufficient funds will be electronically withdrawn for the amount of the check plus the NSF check fee of $50.00.
 
We except [] Cash/Check         [] Visa       [] Master Card     [] Discover
 
How did you become aware of our clinic? (Whom May we thank?) _____________________________
 

 
Pet # 1
Pet # 2
Pet # 3
NAME
 
 
 
BREED
 
 
 
DATE OF BIRTH
 
 
 
COLOR
 
 
 
SEX/SPAYED OR NEUTERED?
 
 
 

 
YOUR DOGS VACCINATION HISTORY:
 

RABIES
 
                          
 
DHLP PARVO CORONA
 
 
 
BORDETELLA
 
 
 
FECAL (STOOL SAMPLE)
 
 
 
HEARTWORM TEST/PREVENTION?
 
 
 

 
YOUR CATS VACCINATION HISTORY:
 

RABIES
 
                          
 
FVRCPC
 
 
 
FIV/FELINE LEUKEMIA
 
 
 
FECAL (STOOL SAMPLE)
 
 
 

 
Our pet(s) is:                               [] Member of family            [] Childs pet              [] Backyard pet
 
Any previous serious illnesses or surgeries? __________________________________________________
 
Any allergies to vaccinations or medications? __________________________________________________
 
Is your pet on any special diets or medications? ________________________________________________
 
Would you like to be present during treatment to your pet?                [] Yes              [] No
 

 

 

 

 

 

VIRGINIA VETERINARY DISCLOSURE FORM 

 

 
COMPANION PET CARE CLINIC HAS BUSINESS AND MEDICAL STAFFING HOURS AS FOLLOWS:
 
 
 MONDAY THRU FRIDAY                     8:00 AM – 6:00 PM
 
SATURDAY                                            8:00 AM – 12:00 PM
 
SUNDAY                                                       CLOSED
 
                    
 
 
THIS IS TO INFORM YOU THAT ALTHOUGH OUR DOCTORS AND STAFF STILL COME IN TO CARE FOR YOUR PET, WE HAVE NO IN-HOUSE, ON-DUTY CONTINOUS MEDICAL STAFF CARE OVERNIGHT, ON WEEKENDS AFTER CLOSING, OR ON HOLIDAYS. SHOULD YOUR PET NEED CONSTANT MEDICAL SUPERVISION, YOU MAY TRANSPORT YOUR PET TO THE EMERGENCY VETERINARY SERVICES OF ROANOKE.
 
 
THANK YOU
 
 
 
I HAVE READ THIS FORM AND I AM AWARE OF THE ABOVE STAFFING HOURS. 
 
 
 
_________________________________                         ____________
OWNER/GUARDIAN SIGNATURE                         DATE