Welcome Form

Welcome to Veterinary Village!
Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you have about your pet's health. To insure the best care possible, please take the time to read and fill out this form completely. Thank You!
Your Name*
Co-Owner's Name
Street Address
City*
State*
Zip*
Email
example@example.com
Phone #1*
Please enter a valid phone number.
Is Phone #1 a Home, Work, or Cell?
if a cell, then who's cell?
Phone #2
Please enter a valid phone number.
Is Phone #2 a Home, Work, or Cell?
if a cell, then who's cell?
Phone #3
Please enter a valid phone number.
Is Phone #3 a Home, Work, or Cell?
if a cell, then who's cell?
Phone #4
Please enter a valid phone number.
Is Phone #4 a Home, Work, or Cell?
if a cell, then who's cell?
Place of Employment
Employment Phone #
Please enter a valid phone number.
How Did You Hear About Us?

Veterinary PracticeFriend or Family MemeberInternet SearchSocial Media (Facebook/Twitter)Radio AdDrove ByDog Show or Kennel ClubSeminarOther
All fees are due at the time services are rendered.

We accept Cash, Check, Visa, MasterCard, American Express, Discover & Care Credit.

I hereby authorize Veterinary Village LLC and their employees to reasonably use any photographic images taken by them of my pets, my children and myself in print and internet formats with no compensation or consideration.
Patient Information

Thank You for giving us the opportunity to care for your pet. To insure the best care possible, please take the time to fill in this form completely.
Patient #1
Name*
Species

DogCatOther
Breed
Color
Birthdate

MonthDayYear
Date
Gender*

MaleNeutered MaleFemaleSpayed Female
Food or Medication Allergies
Current Meds/Prescriptions
Vaccines due on
Heartworm/Fecal test due on
Patient #2
Name
Species

DogCatOther
Breed
Color
Birthdate

MonthDayYear
Date
Gender

MaleNeutered MaleFemaleSpayed Female
Food or Medication Allergies
Current Meds/Prescriptions
Vaccines due on
Heartworm/Fecal test due on
Patient #3
Name
Species

DogCatOther
Breed
Color
Birthdate

MonthDayYear
Date
Gender

MaleNeutered MaleFemaleSpayed Female
Food or Medication Allergies
Current Meds/Prescriptions
Vaccines due on
Heartworm/Fecal test due on
Patient #4
Name
Species

DogCatOther
Breed
Color
Birthdate

MonthDayYear
Date
Gender

MaleNeutered MaleFemaleSpayed Female
Food or Medication Allergies
Current Meds/Prescriptions
Vaccines due on
Heartworm/Fecal test due on
Co-Owner or Agent Information
Other than the owner(s) listed in the beginning, are there any other persons to whom you give primary responsibility for the care of the patient(s)?

YesNo
If you selected "Yes" above, please list the name and telephone number for the other persons in the order you wish for us to contact them in the event that you are not available (must be at least 18 years old).
Co-Owner 1 Name
Co-Owner 1 Phone
Please enter a valid phone number.
Co-Owner 2 Name
Co-Owner 2 Phone
Please enter a valid phone number.
Informed Consent
I understand that my veterinarian will need to communicate with me, or someone designated by me, prior to treatment of my pet(s) in order to obtain informed consent. For purposes of obtaining informed consent, I direct my veterinarian as follows:
Informed consent may ONLY be provided by me

YesNo
Informed consent may be provided by me OR the co-owners/agents above

YesNo
Please list any special directions regarding who the veterinarian should contact to obtain informed consent in an emergency if I, any co-owner or agent are not available
I further acknowledge that no guarantee has been made as to results that may be obtained. I understand that complications may arise which cannot be predicted and that I will be held financially responsible for any veterinary medical care necessitated by those complications.*
Signature
Date*

MonthDayYear
Date
Should be Empty:

Welcome to Veterinary Village!

Patient Information

Patient #1

Patient #2

Patient #3

Patient #4

Co-Owner or Agent Information

Informed Consent