New Client Form

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

YOUR (Owner) Date of Birth

Co-Owner's Name

Co-Owner's Mobile Phone

Co-Owner's Work Phone

Prior Vet Clinic Name

Prior Vet Phone

Are you being referred to us by another veterinarian?

Yes

Pet Information

Pet Name

Species

Breed

Date of Birth/Estimated Age

Color

Sex

Male

Female

Neutered Male

Spayed Female

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.

SMS marketing consent

I consent to receive marketing SMS

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.

Payment Policy

Due to operational costs we have established the following policy of PAYMENT IN FULL at the time services are rendered. We accept VISA, MASTERCARD, DISCOVER, AMEX, CARE CREDIT, PERSONAL CHECK, or CASH. A 50% deposit is required with all major hospital or surgical cases. In case of non-payment the owner is responsible for all collection fees.

On all returned checks there is a $30.00 returned check fee added to the balance. Appointments must be canceled 24hrs prior to the scheduled appointment. In the event of a no show, you will be required to pay a reservation fee prior to all of your pets' future appointments.

Payment policy agreement

I HEREBY UNDERSTAND AND AGREE TO THE AFOREMENTIONED PAYMENT POLICY OF THE BON AIR ANIMAL HOSPITAL.

Cost liability agreement

I UNDERSTAND THAT I AM LIABLE FOR ANY COSTS ASSOCIATED WITH THE CARE OR TREATMENT OF ANY ANIMAL, PERSONAL PET OR OTHERWISE, BROUGHT INTO THE CLINIC FOR EVALUATION AND/OR TREATMENT.

State of Virginia Client Disclosure Form

The Bon Air Animal Hospital is open from 8 AM to 7 PM Monday through Friday and Saturdays 9 AM to 12PM. Doctor's hours are from 9 AM-6 PM Monday through Friday and Saturdays 9 AM-12 PM. This is to inform you that medical personnel are on duty during these hours only. NO IN-HOUSE, NO ON-DUTY, CONTINUOUS MEDICAL CARE IS AVAILABLE EXCEPT FOR THE ABOVE STATED HOURS.

Staff hours disclosure agreement

I have read this form and am aware of the above staff hours.

Owner Signature

Signature