Chatham Animal Clinic - New Client Form

1
Owner Information* This field is required.
Name
Email
Phone
Employer
Work Number
2
Do we have permission to call you at work?
Yes
No
3
Do you have a spouse?
Yes
No
4
Spouse Information
Name
Phone
5
How did you hear about us?
Social Media
Google
Referral
Other
6
Who may we thank for referring you?
7
Would you like to receive email vaccination reminders?
YESNO
8
MEDICAL STAFFING HOURS DISCLOSURE

As Required by the Legislature of Virginia

Chatham Animal Clinic's medical staffing hours are as follows:

Monday-Friday: 7:30 am to 12 noon*, 2:00 pm to 5:00 pm*

Saturday: 7:30 am to 12:00 noon*, 2:00 pm to 5:00 pm*

(*Excluding holidays)

We do not have in-house, on-duty continuous medical staff except during the hours above.
9
A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT.

I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND TREAT MY PET AND I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED.

We gladly accept Cash, Check, Mastercard, Visa, Discover and Care Credit
PAYMENT IS REQUIRED AT TIME OF SERVICE
10
Signature* This field is required.
Clear
11
Date* This field is required.
Date
Year
Month
Day
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