New Client Form Online – Williamsburg Veterinary Clinic

Name *

First

Last

Driver's License # and Expiration Date

Email *

*Emails are utilized for reminders and hospital communications only

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Cell Phone

Employer

Spouse/Co-Owner

First

Last

Co-Owner Phone

Do you have pet insurance? If so, through which company?

Please let us know how you heard about our clinic!

Facebook
Google
Drive By
Referral

Whom may we thank?

Pet Name *

Species *

Cat
Dog
Ferret
Other

What type of pet?

Sex

Male
Spayed Male
Female
Neutered Female

Breed

Birthday

Color

Has your pet received vaccinations within the last year? Please provide records if possible.

Yes
No

Is your pet currently on any medications? If so, which ones?

Is your pet currently on any Heartworm or Flea Prevention? If so, which one(s)?

Do you have any other pets in the household?

Does your pet have any known anxieties/stress triggers?

Does your pet have any known allergies or reactions to medications?

Photo Release: I authorize the taking of photographs of my pets by the staff of Williamsburg Veterinary Clinic, LLC for the purpose of posting on Facebook, the WVC website, and other online sites used for the professional and promotional purposes by the LLC. The photos will remain the property of the LLC and will be made available to the owner upon request at the discretion of management. *

I have read and understand.

Authorization: As the rightful owner of the above described pet, I hereby authorize the veterinary medical staff of Williamsburg Veterinary Clinic to examine, prescribe for, and treat said pet. I assume all responsibility for the charges incurred associated with these services. A treatment plan and financial estimate for recommended services will be provided for all hospitalized pets and upon request at any time. I understand that all charges are to be paid when services are rendered and that a deposit is required for all admitted pets. *

I have read and understand.

Our clinic accepts and offers application for Care Credit, an independent medical credit line company which provides interest-free payment options. We also accept Visa, Mastercard, Discover, American Express and cash payments. No personal checks will be accepted. Payment is due when services are rendered. *

I have read and understand.

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