Client Registration Form

Countryside Animal Clinic Registration
Primary Owner*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Phone Number to Reach You*

Area CodePhone Number
Preferred Email*
example@example.com
Your Date of Birth*

MonthDayYear
Preferred Form of Communication*

CallTextEmail
How were you referred to our clinic?*

Drive by / SignOnline SearchCurrent ClientPrevious ClientOther
If referred by a previous or current client, please enter their name here

First NameLast Name
Additional Owner / Authorized to Make Medical & Financial Decisions

First NameLast Name
Relationship to Primary Owner
Phone Number

Area CodePhone Number
Email
example@example.com
Pet's Name(s)*
Please provide the information of your previous vet so we can request records prior to your scheduled appointment. *

Hospital/ClinicPhone Number
If you have access to your pet's previous history, please attach the file here.

Browse Files

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If you would like to attach a photo of your pet for our files, please do so here.

Browse Files

Cancelof
We periodically post photos of our patients online (FB & IG). Please indicate if we have your permission to do so, using pet name only.

Yes, it's okayNo, thank you
Any previous patient history we should be aware of?
Any additional information that you would like the Veterinarian to be aware of?
Countryside Animal Clinic Client Registration - Signature*
FINANCIAL RESPONSIBILITY POLICIES: Full payment is due at the time of service. Returned checks and failed PAW Plan payments are subject to a $25.00 reprocessing fee. Account balances not paid in a timely manner will be assessed an interest rate of 1.5% per month (18% per annum). Outstanding debts with nonpayment of more than 90 days will be referred to our collection agency and the credit bureaus.
FINANCIAL RESPONSIBILITY POLICIES - Signature*
COUNTRYSIDE ANIMAL CLINIC

STATE OF VIRGINIA HOURS DISCLOSURE FORM

Countryside Animal Clinic is pleased to serve you and has staff on site during these hours:

Monday - Friday 7:30 am - 7:00 pm

Saturday 8:00 am - 3:00 pm

We are closed on Sundays and the following major holidays:

New Year’s Day, Memorial Day, July 4th, Labor Day, Thanksgiving, and Christmas.

Please note that except during the above noted hours of operation, continuous veterinary medical care is not available.

I have read the above statement and am aware of the clinic staffing hours.
STATE OF VIRGINIA HOURS DISCLOSURE FORM - Signature*
Should be Empty:

Countryside Animal Clinic Registration