Client Information
Your Full Name
Required
Your Address
Email (for office use only)
Phone Number
Required
Secondary Name on Account
Emergency Contact (other than yourself) Name and Relationship
Required
Patients Name
Required
Breed
Required
Color and Markings
Required
Sex
Required
If your pet is on long-term medications, please list them below
List any chronic problems?
If your pet is allergic to any medications or vaccines, please list them below.
How did you hear about us?
VA Vet Disclosure
This Vet Disclosure form is the second of three forms to be filled out before your first visit. Once you have completed this form please move on to the final part, the PreVisit Form, by clicking next.
Our business and medical staffing hours are as follows:
Monday 8:00 am - 6:00 pm
We are closed Sundays and holidays.
This is to inform you that we have no in-house, on duty continuous medical staff care:
Overnight from closing time to opening time at 8:00 am.
Weekends from closing Saturday at 12 noon to opening time Monday morning at 8:00 am.
Holidays from closing time the day before the holiday to opening time Monday morning at 8:00 am.
Holidays falling on Monday from closing time on Saturday at 12 noon to opening time on Tuesday at 8:00 am.
Animals hospitalized overnight are checked as needed through the night by the doctor and/or the technician. If continuous care is deemed necessary by the doctor, animals may be transported by the owner to the after-hours emergency hospital.
Virginia State Code § 54.1-3806.1.
Any animal medical care facility in the Commonwealth, excluding those facilities dealing with livestock, as defined in § 3.2-5900 , which does not provide continuous medical care for all animals left in its charge shall, before taking charge of an animal, provide the client or agent thereof with a disclosure form which specifies the hours and days when continuous medical care is not available at the facility. Such form shall be separate and apart from any other form or information provided by the facility. Except in emergency situations when time or circumstances do not permit, such facilities may take charge of an animal only after the client or agent thereof has signed the disclosure form and returned it to the facility. Only one signed form per client shall be required, and the form shall be kept on file by the facility.
1991, c. 621; 1998, c. 158 .
Name
Required
Previsit Questionnaire
This PreVisit form is the final of three forms to be filled out before your first visit. Once you have completed all three forms we will review and be in touch to schedule your first visit. Thank you!
Patients Full Name
Required
Age
Required
Breed
Required
Most Recent Weight
Required
Sex
Required
What problem is your pet experiencing
When did the problem start?
Is the problem the same, better, or worse?
Has a similar problem happened in the past?
Are any medications/supplements being administered, including
Heartworm and Flea & Tick Preventative?
What type of food do you feed your pet, including amount and frequency?
Is your pet on a grain-free diet?
Has their eating changed?
Has your pet been vaccinated recently?
Any weight loss/gain?
Any increase or decrease in water consumption?
Any changes in bowel movements?
Any exposure to toxins?
Any other medical history?
Additional Comments:
Best phone number to call during the appointment
Required
