Owner's Date of Birth*

For controlled drug prescription reporting purposes

Spouse/Other

Spouse/Other’s Date of Birth

For controlled drug prescription reporting purposes

Cell Phone*

Work Phone

Home Phone

Email Address*

Spouse/Other Cell Phone*

Spouse/Other Work Phone

Spouse/Other Home Phone

Alternate Email

Comments

Pet’s Name, if known

Payment for all services is due in full at the time of service. An estimate can be provided upon request; however, please note that it is an estimate, not a binding quote. The final cost may vary based on actual time, materials, or other factors that arise during the course of service.

We accept credit cards, debit cards, cash and checks. A 3% fee will be added to all credit card payments. This fee is not applied to cash, check and debit cards. Any returned checks will be subject to a returned check fee of $35 and forfeit the promisors’ options for check payments in the future. If payment is not received at the time of service, a $15 monthly billing fee will be applied to your account. This fee will be assessed each month until the outstanding balance is paid in full. If your balance remains unpaid for more than 90 days, we reserve the right to initiate collection efforts. You agree to be responsible for any collection costs, including but not limited to: Collection Agency Fees: You will be responsible for any fees incurred from third-party collection agencies hired to recover the outstanding balance. Attorney Fees: If the account is referred to an attorney for legal action, you will be responsible for any legal fees, court costs, and attorney fees incurred in the process of collecting the debt.

By scheduling services with us, you agree to abide by the terms of this payment policy. If you have any questions or con- cerns regarding our payment policy, please contact us. I also agree to exclusive venue and jurisdiction of Fairfax County, Virginia for all matters of litigation regardless of the location of the promisor.

Name of veterinarian and clinic that has most recent medical history

Signature*

Date*

PET MEDICAL HISTORY

Pet's Name*

Species (Dog/Cat/Other)*

Breed*

Description (Color)*

Date of Birth*

Length Of Time Owned

Microchip Number (If applicable)

Diet (kind of pet food)

How Often Fed

Type Of Grooming Products

Hours Spent Outside Each Day

Allergies

Heartworm Prevention

Dentistry

Prior Illness

Prior Surgery

Pet's Name*

Species (Dog/Cat/Other)*

Breed*

Description (Color)*

Date of Birth*

Length Of Time Owned

Microchip Number (If applicable)

Diet (kind of pet food)

How Often Fed

Type Of Grooming Products

Hours Spent Outside Each Day

Allergies

Heartworm Prevention

Dentistry

Prior Illness

Prior Surgery

Pet's Name*

Species (Dog/Cat/Other)*

Breed*

Description (Color)*

Date of Birth*

Length Of Time Owned

Microchip Number (If applicable)

Diet (kind of pet food)

How Often Fed

Type Of Grooming Products

Hours Spent Outside Each Day

Allergies

Heartworm Prevention

Dentistry

Prior Illness

Prior Surgery

CAPTACHA

Email

This field is for validation purposes and should be left unchanged.

New Client Form

New Client Form

PET MEDICAL HISTORY

Request an Appointment

Address

Contact Information

Hospital Hours

AFTER-HOURS EMERGENCIES

Get in Touch