Short Pump New Client Registration Form

New Client Registration
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email*
example@example.com
How Did You Hear About Our Practice?

Walked/Drove ByTV/Radio/NewspaperHospital EmployeeGoogle/Bing/YahooCard/Flyer/MailerFacebook/InstagramYelpShelterHospital/VeterinarianExisting ClientOther - Don't Remember
Which hospital/veterinarian?
Which existing client?
Pet Information
Pet #1 Name
Species
Breed
Color
Date of Birth or Age (if known)
Gender

MaleFemale
Spayed/Neutered

YesNo
Please provide the name(s) of your previous veterinary hospital(s) for us to contact to request records.
Do you have another pet you would like to add?

YesNo
Pet #2 Name
Species
Breed
Color
Date of Birth or Age (if known)
Gender

MaleFemale
Spayed/Neutered

YesNo
Please provide the name(s) of your previous veterinary hospital(s) for us to contact to request records.
Photo Consent: We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this.

Yes, I authorize Short Pump Animal Hospital to share my pet's photo and story.No, I do not authorize this.
Missed Appointment Policy: To meet the needs of all our clients, we see our patients by appointment only. We understand that from time to time, appointments may need to be changed or canceled. We request 24 hours notice for appointment cancellations. Therefore, if you do not cancel an appointment, we must charge you for the visit. The charge for missed appointments is $70, which is equal to the examination fee.*

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Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. 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 or prolonged hospitalization.*

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Payment Options: Our mission is to deliver the finest, most effective health care treatment available today. Following diagnosis, the doctor will advise you on our plan for treatment. We offer the following options for payment: Cash, Visa, MasterCard, Discover, American Express or Care Credit. If you choose this option and do not currently have an open Care Credit account, please ask the receptionist for an application or go to www.carecredit.com/apply to fill out an application. We do not accept personal checks. By signing below, you assume responsibility for all charges incurred for the care of your animals. ALL PROFESSIONAL FEES ARE DUE THE TIME SERVICES ARE RENDERED.*

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Virginia Veterinary Disclosure: We are a full service veterinary medical and surgical facility. Our hours of operation are as follows: Monday through Friday: 7:30 AM- 6:30 PM. Closed Saturday, Sunday and major holidays. This disclosure form is provided to inform you that we have no in-house, on duty continuous medical staff during our closed hours. Should your pet have a medical emergency, please call the following emergency hospitals: Dogwood Veterinary Emergency and Specialty Center: 804-716-4700, VRCC: 804-784-8722 or Veterinary Emergency and Specialty Center: 804-353-9000.*

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ScribbleVet Consent and Release

Our veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording. By signing this agreement:
1. Appointment Recording: You agree that your vet appointments may be
  recorded. If you don’t want to be recorded, let us know.
2. Usage Rights: You grant us permission to share these recordings, and any
  other materials you choose to provide, for the purpose of improved clinical
  documentation.
3. Age Confirmation & Understanding: You affirm that you are at least eighteen
  years old, and that you understand and accept the terms in this agreement.
  We are committed to providing the best care for your pet in a manner comfortable for both of you.
Client Name*
Client Signature*

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Today's Date

MonthDayYear
Date
Should be Empty:

New Client Registration

Owner Information

Pet Information