Updated New Client Registration Packet

Brandermill Animal Hospital

12501 Hull Street Road, Midlothian, VA 23112

(804) 745-4243

Dr. Jennifer Kistler ◦ Dr. Tonya Gudaitis ◦ Dr. Emily Wayne

New Patient/Client Registration

Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs by taking a moment to share some important information we will need to support your pet’s needs today and in the future.

A deposit for the first exam fee ($25.00) will be required to book your first appointment as this reduces no-shows and last-minute cancellations that impact our ability to care for current patients. This is a non-refundable deposit that may be transferred to a rescheduled appointment if reschedule is made 48 hours in advance. Future appointments do not currently require a deposit.

A staff member will reach out to you to schedule as soon as they’ve set you up in our system, usually the same business day.
To ensure proper registration with Brandermill Animal Hospital, please use the same name, address, phone number, and email address across all platforms. If you have any questions, please call or text us at (804)745-4243. Thank you!
Owner Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Spouse/Partner/Other

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Number*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Spouse/Partner/Other Phone
Please enter a valid phone number.
Spouse/Partner/Other Work Phone
Please enter a valid phone number.
Names of all people, including family members who have permission to authorize care/treatment of your pet(s).
Emergency Contact
Emergency Contact Phone Number
Did one of our clients refer you to us?

YesNo
If yes, who can we thank?
If no, how did you first hear about our hospital?

Hospital signGoogleFacebookYelpOther
Photo and Sharing Authorization: We love treating your pets and enjoy the time you allow us to spend with them. On occasion, we would like to capture these moments in photo/video. These photos may be emailed to you as an update on their status/progress, used on our website, or shared on social media sites such as Facebook. Do you authorize us to photograph/video your pet for these purposes?*

YesNo
Peanut Butter Allergy: We like to offer peanut butter to our canine patients to make their visits more positive, but we are aware that some clients have severe peanut allergies. Do you approve us giving your pet peanut butter during their visit?*

YesNo
Late Policy: Please arrive at least 5 minutes prior to your appointment time for check-in. If you arrive more than 10 minutes late for your appointment you will have the option to: Drop your pet off and pick up when ready. (schedule permitting and at veterinarian discretion) Wait to be seen and have a shortened appointment time. Reschedule for another time. *
Please initial to acknowledge
Missed Appointments and Late Cancellation Policy: Please provide at least 24 hours notice if you need to cancel or reschedule your appointment. Missed appointments and late cancellations affect our ability to care for patients in need. Clients with repeated missed appointments and/or late cancellations will be required to pay a $25 per pet deposit to secure future appointments.*
Please initial to acknowledge
Pet Information:
Pet Name *
Pet Age*
Species*
Breed *
Sex*
Color*
Microchip number
Any past medical problems or previous surgeries?
Temperament: Has your pet ever bitten anyone? Is there anything else we should know about their temperament?*

YesNoOther
Please list any additional pets by Name, Age, Species, Breed, Sex and Color: *
Has your pet ever seen another veterinarian?*

YesNo
Name and phone # of previous Veterinarian or Hospital for vaccination/medical history on your pet(s):
You may upload pet records here:

Cancelof
Please note that we must receive medical history at least 48 hours prior to the appointment. If records are not received, we will contact you to reschedule the appointment.
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. Due to Legal restrictions, Prescriptions cannot be returned. We accept Visa, MasterCard, Discover, American Express & Care Credit. I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30days will accrue a monthly finance charge of 2% or 24% per annum). If necessary, a $50.00 collection fee will be applied, plus any charges associated with the collection of the outstanding balance. Return check fee is $50.00. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. *

Clear
Printed Name*
Date*

MonthDayYear
Date
Should be Empty:

To ensure proper registration with Brandermill Animal Hospital, please use the same name, address, phone number, and email address across all platforms. If you have any questions, please call or text us at (804)745-4243. Thank you!

Pet Information: