CLIENT / PATIENT ADMISSION FORM

In preparation for your appointment at Animal Vision Center of Virginia, you may submit this client/patient admission form in-person or through the online form below.

  • CLIENT INFORMATION

  • PATIENT INFORMATION

  • AUTHORIZATION

  • I hereby authorize the veterinarian to examine, prescribe for, or treat my pet(s). I will assume all financial responsibility for any and all charges incurred by my pet(s) while in the care of the doctors at Animal Vision Center of Virginia. I understand that these charges will be paid at the time services are rendered and that a deposit may be required prior to treatment. Animal Vision Center of Virginia accepts cash, VISA, MaserCard, American Express, Discover, Credit Care, and personal check. If paying by check, please provide the following information:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

If you prefer, you may fill out our downloadable form (below) and print to bring with you to your appointment or fax to 757-932-9325