New Client Form - Williamsburg Veterinary Clinic

Client and Contact

First and Last Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone*

Email*

DOB*

How did you become aware of this clinic?

Choose one*

If other, please specify

Emergency Contact Person*

Home Phone*

Cell Phone*

Name of Previous Veterinarian

Phone of Previous Veterinarian

Pet Information

Pet 1

Pet 1 Name*

Sex*

Species*

Breed*

Color*

DOB*

Medical History (vaccinations, current medical conditions, diet):*

Pet 2 (optional)

Pet 2 Name

Sex

Species

Breed

Color

DOB

Medical History (vaccinations, current medical conditions, diet):

Pet 3 (optional)

Pet 3 Name

Sex

Species

Breed

Color

DOB

Medical History (vaccinations, current medical conditions, diet):

Do you already have an appointment scheduled?*

Yes
No

Date of Current Appointment

Time of Current Appointment

:

Agreements

Agreement #1*

Professional fees are to be paid at the same time services are performed.

I agree.

Agreement #2*

In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of the Williamsburg Veterinary Clinic, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.

I agree.

Agreement #3*

It is understood that an estimate of charges will be given for services. No guarantee or assurance can be made as to the results that may be obtained.

I agree.

Agreement #4*

Further, I understand that a deposit of 50% is required before services are performed and I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur.

I agree.

Agreement #5*

I request any and all treatment deemed necessary by the attending veterinarian and agree to pay all charges for services rendered at the time those services are rendered. I understand and agree that any charge which is unpaid shall be subject to a monthly interest charge of two percent (2%) and, should my account be assigned for collection, I will be responsible for all costs and an attorney’s fee of thirty-three and one-third percent (33 1/3%) of all monies due.

I agree .

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