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New Client Form - Animal Wellness Center

Thank you for giving us the opportunity to care for your pet(s)! Please complete the following to the best of your knowledge.

Client Information

First Name

Last Name

Mobile Phone

Work Phone

Address

City

State

Zip

Email

Co-Owner's Name

Co-Owner's Mobile Phone

Co-Owner's Work Phone

Prior Vet Clinic Name

Prior Vet Phone

How did you hear about us?

How did you hear about us?
A
B
C
D
E

Whom may we thank?

Are you being referred to us by another veterinarian?

Are you being referred to us by another veterinarian?
A
B

Pet Information

Pet Name

Species

Breed

Date of Birth/Estimated Age

Color

Sex

Sex
A
B
C
D

Heartworm Prevention

Allergies to Vaccines/Medications

Previous Surgery/Illness

Special Diet/Medications/Supplements

Notes

Authorization & Digital Communication Consent

I authorize the hospital to release my pet’s medical information to other veterinary hospitals, groomers, and kennels, including my phone number, if my lost pet is recovered. I acknowledge that conversations during my pet’s visit may be recorded for quality assurance and service improvement purposes. I hereby grant the hospital all rights, title, and interest in any photographs, images, videos, or audio recordings of my pet or myself taken during my pet’s visit. This includes the use of such materials for promotional purposes, on the hospital’s website, and other marketing materials. If the veterinary team determines that immediate treatment is necessary for the health and well-being of my pet, and I or my co-owner are unable to be reached, I consent to the administration of all reasonable treatments recommended. I assume responsibility for all charges incurred for my pet(s) and understand that payment is due at the time services are rendered.
I understand that the veterinary clinic offers various forms of digital communication to keep me informed about my pet’s health, remind me of upcoming appointments, customer care and health tips. By signing below, I authorize the veterinary clinic to contact me via email, phone, and/or text message (SMS). I understand that I can opt out of these communications at any time by following the unsubscribe instructions in any communication received. Message frequency varies; most commonly monthly updates are expected unless medical needs require more frequent notifications. Message data rate may apply. Reply HELP for assistance or STOP to discontinue SMS.

Untitled checkboxes field
I confirm that I am 18 years of age or older and legally authorized to consent to veterinary treatment and assume financial responsibility the services rendered.

Virginia Veterinary Disclosure Form (Please read carefully)

This is to inform you that Animal Wellness Center has business and medical staffing hours as follows: Monday through Friday 7:30am to 6:00pm; Saturday 7:30am to 1:00pm. We are closed on Sundays and Federal Holidays. Therefore this is to inform you that we have no in-house, on duty medical staff care: (1) OVERNIGHT from closing until opening time the next day; (2) WEEKENDS from closing time Saturday at 1:00pm until 7:30am Monday morning; (3) HOLIDAYS from closing time before the holiday to opening time the day after the holiday; (4) HOLIDAYS FALLING ON A MONDAY from closing time Saturday at 1:00pm until 7:30am Tuesday morning.
24 hour in-house medical care is available during those times noted (in 1, 2, 3, 4) and is provided by Greenbrier Emergency Animal Hospital, which can be reached by calling (434)202-1616, or Veterinary Emergency Services in Verona at (540)453-8862.
I have read the above document and I am aware of the above staffing hours.

Owner Signature

Signature

Pet #2 Information

Pet Name

Species

Breed

Date of Birth/Estimated Age

Color

Sex

Sex
A
B
C
D

Heartworm Prevention

Allergies to Vaccines/Medications

Previous Surgery/Illness

Special Diet/Medications/Supplements

Notes

Pet #3 Information

Pet Name

Species

Breed

Date of Birth/Estimated Age

Color

Sex

Sex
A
B
C
D

Heartworm Prevention

Allergies to Vaccines/Medications

Previous Surgery/Illness

Special Diet/Medications/Supplements

Notes

Pet #4 Information

Pet Name

Species

Breed

Date of Birth/Estimated Age

Color

Sex

Sex
A
B
C
D

Heartworm Prevention

Allergies to Vaccines/Medications

Previous Surgery/Illness

Special Diet/Medications/Supplements

Notes