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
Is the Primary Phone Number a

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.
How did you hear about us:*

Family /FriendFacebookOnline SearchOther
If you were referred by a family member or friend, please let us know who so we can thank them.
How would you like to be contacted for reminder services?*

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.
Date*

MonthDayYear
Signature*

Clear
Should be Empty:

New Client Registration

NEW CLIENT CONSENT