Fairfax Veterinary Hospital New Client Form Bundle

Fairfax Veterinary Hospital New Client Form

Please complete and submit form prior to your visit.
Owner's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Owner Date of Birth
Secondary Owner's Name

First NameLast Name
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred contact method
Family allergies (include food and envrionmental)
In case of emergency and you are unreachable, who is a third party we can call that is authorized to make decisions for your pet(s)? Include the person's name and contact information.
How did you hear about us?

Payment Information

Payment is required at the time of serivce!
Employer's Name
Social Security Number or Driver's License Number (please provide issuing state of license)
We require payment in full at the time services are rendered. For your convenience we do accept Cash, Visa, Mastercard, Care Credit and Checks (with appropriate I.D. and not over $200.) If for any reason a portion of the balance remains unpaid at the time of service, the client agrees to pay a five-dollar processing fee that will be assessed monthly in addition to 1.5% interest on balances older than 30 days. In the event that a client defaults on payment, the client also agrees to pay all costs (including but not limited to collection and/or reasonable attorney’s fees, court costs and any other fees or costs that occur during normal collection procedures).
Signature

New Patient Information
Pet's Name
Breed
Date of Birth/Age
Sex
Color
Current Medications
Current Diet (please include how often and how much your pet is fed)
Allergies
Diagnosed Medical Conditions
Current Medical Conditions/Concerns
How long has the pet been with you?
Is anyone else (other than primary and secondary owner's) authorized to make decisions for this pet?
If yes, please provide person's name and contact information.
Do you give us permission to contact previous veterinarians to request records for your pet?
Please provide the name of previous veterinarian(s).
Please upload a copy of your pet's records if available.

Cancelof

Photo/Video Release
Members of Fairfax Veterinary Hospital dedicate our lives to caring for animals and we love sharing our stories and memories with our FVH family via social media and other publications. In order to do this, we kindly ask your permission to post images of your pet.

Photo/Video Release and Liability Release:

I, Full Name* , hereby permit Fairfax Veterinary Hospital to use pictures and videos taken at the hospital, in which my pet may appear, for purposes of communications and marketing about the hospital. No personal information will ever be included in communications or marketing materials. The results are considered the property of Fairfax Veterinary Hospital and may not be sold or reused without express consent of Fairfax Veterinary Hospital.
I understand the above and:
Signature
Should be Empty:

Fairfax Veterinary Hospital New Client Form