Client / Patient Admission Form

CLIENT INFORMATION

Owner's Name:*

First Last

Co-Owner's Name:

First Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Primary Phone*

Cell Phone*

Employer*

Preferred Method of Contact*

Primary Phone
Cell Phone
Text
Email

PATIENT INFORMATION

Pet's Name:*

Date of Birth / Age*

Breed*

Color*

Species*

Canine
Feline

Sex*

Intact Male
Neutered Male
Intact Female
Spayed Female

Primary Veterinary Clinic*

Primary Veterinarian

Reason For Visit*

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:

Driver's License Number and State*

Date of Birth*

Cancellation & No-Show Policy*

If I have to cancel my appointment with less than 24-hour notice, or do not show up for my scheduled appointment, I understand that I will be charged a $40 cancellation fee to be paid prior to rescheduling this appointment or refilling previously prescribed medications.

I have read and accept these terms

Electronic Client Signature*

Date

Check box if you would NOT like to receive emails from Animal Vision Center of VA
Check box if you would NOT like your pet’s picture to be featured in social media
Check box to OPT-OUT of using your pet’s medical information for research purposes

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Phone

This field is for validation purposes and should be left unchanged.

CLIENT INFORMATION

PATIENT INFORMATION

AUTHORIZATION