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Phone:
(757) 253-7387
| Fax: (757) 585-7595 | Mon-Fri: 7:30AM - 6PM | Sat, Sun: Closed
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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
*
Hospital Sign
Internet
Another Client
Advertisement
Social Media
Other
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
*
Canine
Feline
Exotic
Avian
Reptile
Breed
*
Color
*
DOB
*
Medical History (vaccinations, current medical conditions, diet):
*
Pet 2 (optional)
Pet 2 Name
Sex
Species
Canine
Feline
Exotic
Avian
Reptile
Breed
Color
DOB
Medical History (vaccinations, current medical conditions, diet):
Pet 3 (optional)
Pet 3 Name
Sex
Species
Canine
Feline
Exotic
Avian
Reptile
Breed
Color
DOB
Medical History (vaccinations, current medical conditions, diet):
Do you already have an appointment scheduled?
*
Yes
No
Date of Current Appointment
MM slash DD slash YYYY
Time of Current Appointment
:
Hours
Minutes
AM
PM
AM/PM
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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