New Client Registration

New Client Registration
If you have records to provide for your pets(s), please email them to wac@williamsburganimalclinic.com
Name*

First NameLast Name
Spouse or Partners Name*
Primary owners E mail*
example@example.com
Phone number*

Area CodePhone Number
LandlineMobile
Please provide any additional phone numbers you would like us to have ( ie work). Please provide us with contact information for spouse/partner.*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address if different than your mailing address.
Family /FriendFacebookOnline SearchOther
If you were referred by a family member or friend, please let us know who so we can thank them.
Email (Our preferred means of contact)
NEW CLIENT CONSENT

Please type your name and date to acknowledge the following statement.
I HEREBY AUTHORIZE THE STAFF AT WILLIAMSBURG ANIMAL CLINIC LLC TO EXAMINE , PRESCRIBE FOR AND OR TREAT MY PET(S).

I assume responsibility for all charges incurred in the care of my animal(s). I also understand that these charges will be paid at the time of release, and that a deposit may be required for surgical treatment.

I understand that any credit granted shall be paid promptyly in accordance with terms and agreements. A finance charge is applied to all accounts unpaid after 30 days. This is computed by a periodic rate of 1.5% per month, which is the annual percentage rate of 18.00%. Minimum charge is $3.00. I further agree that in the event of default of payment, I will pay all reasonable collection charges and /or attorney fees.
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Date*

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Signature*

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New Client Registration

NEW CLIENT CONSENT

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