New Patient Registration Form

Please fill out the information below and return it to us prior to your pet's first appointment.

Name*

First NameLast Name

Phone Number

Please enter a valid phone number.

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Name*

Is the patient a*

DogCatOther

Breed*

What color is your pet?*

Date of Birth or approximate age?*

Is your pet ?*

Is your pet microchipped?*

YesNoI don't know please scan my pet.I would like information about micro chipping

Previous Veterinarian*

Previous illness/injury:*

Current medications . Please include dosage and frequency:*

Is your pet on Heartworm Preventative*

YesNo

Is your pet on flea and tick preventatives?

YesNo

Does you have pet insurance?*

YesNoI would like information about pet insurance

Please let us know anything about your pet that you think is important : *

Please type your name and date to acknowledge the following statement.

I HEREBY AUTHORIZE THE STAFF OF 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 this animal. 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 promptly 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.

Name*

Date