Battletown Animal Clinic - New Client Form

3823 Lord Fairfax Highway
Berryville, Virginia 22611
540-955-2171 | 540-955-1716 | battletownanimalclinic@gmail.com
www.battletownanimalclinic.com

Rachael Nuzzo, DVM Holly Nightingale, DVM

Erin Rockwell, DVM Brittany Jones, DVM

Owner Information:

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Physical Address if the above is a PO box

CityState / Province

Postal / Zip Code

Spouse's Name

First NameLast Name

Home Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Employer*

Spouse Employer

Spouse Email

example@example.com

Spouse's Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Notice:

The State of Virginia requires that we notify you that continuous medical care is not available at this facility from 5:00pm 8:00am Monday through Thursday and from 5:00pm Friday until 8:00am the following Monday. If we feel that your pet needs continuous care during these hours, we will notify you and make arrangements to transfer your pet 24-hour care facility. In case of an emergency, we will attempt to contact you to discuss and get permission for treatment. If we cannot reach you in a timely manner, we will act in the best interest of your pet.

Responsible Party Information:

In all cases, professional fees, product purchases, all costs related to treatment, testing and boarding are the responsibility of the client, spouse, guardian, or co-owner of the animal(s). There will be a $75.00 charge on all returned checks.

Payment is due in full at the time of service:

There will be a $70.00 cancellation fee for all appointments in which a client fails to show during the scheduled appointment time without 24-hour advance notice.

Signature (must be over 18 years old)*

Date*