New Client Registration Form

New Client Registration Form

13825 Village Mill Dr, Midlothian, VA 23114 Phone (804) 348-8808
Owner Name*

First NameLast Name
Co-Owner Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Owner Cell Phone Number*

Area CodePhone Number
Co-Owner Cell Phone Number

Area CodePhone Number
Home/Work Phone Number

Area CodePhone Number
When contacting you regarding prescription refills, are text notifications acceptable?

YesNo
Driver's License Number
Please take photo of Driver's License for our records
Employer Name/ Address
Co-Owner Employer Name/ Address
How did you hear about us?

GoogleYelpFacebookInstagramOtherReferred by employeeOther
Patient Name*
Gender*

MaleFemaleUnknown
Spayed/Neutered?

YesNo
Age/ Date of Birth*
Species*
Breed
Color
Previous Veterinary Hospital
Vaccinations

Oasis Veterinary Hospital requires verification of veterinarian administered vaccination of the following prior to admittance for hospitalization, surgery, and/or boarding:

Canines: Distemper/Parvo, Bordetella(Kennel Cough), Influenza, Rabies
Felines: Distemper, Rabies
Signature*

Clear
Payment Timing and Deposits

I understand that all fees are due and payable when services are rendered. A deposit will be required for all new patients into the hospital. Upon request, an estimate can be given by the doctor, prior to any pets receiving medical treatment in office or for hospitalization; provided that the immediate health conditions of your pet allow it.

Lateness & Cancelation Policy

Oasis Veterinary Hospital has a 10-minute late policy, which states: If you're more than 10 minutes late for your appointment, you'll be marked as a no-show which could result in a reschedule on all or part of you and your pet’s scheduled services. Please call us if you are running late so we can best accommodate you. We require 24-hour notice for ALL cancellations or reschedules. If you cancel or reschedule without a 24-hour notice or no-show for your appointment, a deposit will be required in order to reschedule, and a no-show fee will be applied.

Returned Checks

In the event that your check is initially returned for insufficient funds, but ultimately satisfied by your bank, then a $35 returned check fee will be added to your unpaid account balance.

In the event that your check is returned for insufficient funds and not ultimately satisfied by your bank, then the amount of the returned check plus $35 returned check fee will be added to your unpaid account balance, and the total will be considered late and the account balance must paid in full in cash or a bank cashier's check.

Late Payment and Delinquent Accounts

Any unpaid account balances which are not paid within 10 days of the date of the invoice become a delinquent account and are subject to 2% monthly finance charge. Furthermore, at our sole discretion, we may submit any delinquent account to our attorney for collections. With respect to delinquent account(s), you agree that in addition to the returned check fee and the monthly finance charge, you will be responsible for attorney’s fees and all other costs of collection, including but not limited to all applicable court costs.
Signature*

Clear
PHOTO CONSENT: I authorize Oasis Veterinary Hospital to take and display photos of my pet(s) on their social media sites: website, Facebook, Instagram, Twitter, etc and/or internal media site and marketing materials.*

YesNo

New Client Registration Form

Oasis Veterinary Hospital