Tuesday, September 07, 2010
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American Animal Hospital Association

 

REGISTRATION FOR NEW CLIENT
If you prefer to download our PDF form instead of using our online form, please click the link below and fax the completed form to 804-794-3015.
Registration for New Client
Personal Information
Date: September 7, 2010
Name:
Address:
City, State, Zip ,
Home Phone:  (xxx) xxx-xxxx
Work Phone:  (xxx) xxx-xxxx
Cell Phone:  (xxx) xxx-xxxx
Physical Address (if different):
E-mail:
Employer:
Are you currently in the Military?: Yes   No
Alternate Contact:  
Alternate Contact Phone:
   
How did you become aware of our Hospital?
Yellow Pages   Our Sign   Referring Veterinarian or Hospital
Our Website (www.macvetva.com)   Other
Personal Recommendation from:
Have you been to a veterinarian before? Yes   No
If YES, who?
Reason for change?
   
Your Pet's Information (#1)
Pet's Name:
Gender / Etc.: Male   Female   /   Canine   Feline
Neutered or Spayed? Yes   No
Breed:
Color:
Birth Date:
 
Dog Dates: (MM/YY)   Cat Dates: (MM/YY)  
DHPP: RCP:
Bordetella: FELV:
Rabies: Rabies:
Deworm: Deworm:
Fecal: Fecal:
Heartworm Check:    
       
Your Pet's Information (#2)
Pet's Name:
Gender / Etc.: Male   Female   /   Canine   Feline
Neutered or Spayed? Yes   No
Breed:
Color:
Birth Date:
 
Dog Dates: (MM/YY)   Cat Dates: (MM/YY)  
DHPP: RCP:
Bordetella: FELV:
Rabies: Rabies:
Deworm: Deworm:
Fecal: Fecal:
Heartworm Check:    
       
Credit Information
FEES FOR PROFESSIONAL SERVICES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED
The undersigned acknowledges and certifies that in admitting their pet(s) to Midlothian Animal Clinic for diagnostics, treatment or surgical procedures, they authorize the veterinarians and their support staff to administer such treatment and/or perform such diagnostic or surgical procedures when deemed necessary.  An estimate of fees will be given for anticipated services.  No guarantees or assurances can be made to the results that may be obtained.  It is also understood that fees may exceed a given estimate should complications arise.  I understand that any fees will be paid at the time of release and that a deposit may be required for surgery or for any prolonged treatment.  A finance charge on any outstanding balance will be assessed at a minimum of $5.00 or 2% per month after 30 days. If necessary, a $30.00 collection fee will be applied, plus any charges associated with the collection of the outstanding balance.  There is a $25.00 fee on any check returned back to us.
Driver's License Number:
Expiration Date:
State:
Date of Birth:
   
AGREE: I AGREE TO THE ABOVE SUBMISSION AND CONDITIONS OF SUBMITTAL
    

 

14411 Sommerville Court • Midlothian, VA 23113 • 804-794-2099 • Fax 804-794-3015 • info@macvetva.com