New Client Packet

New Client? Please fill out this new client packet before your first appointment.

New Client Packet

Required Fields are Marked [*]

Step 1 of 5

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Owner’ Name:(Required)

First Last

Email(Required)

Primary Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Driver's License State and #(Required)

Employer(Required)

Work Phone Number

Spouse / Additional Owner Name:

Spouse / Additional Owner Phone:

Spouse / Additional Owner Driver's License

Pet Information

Pet Name(Required)

Species(Required)

Dog

Cat

Bird

Reptile

Rabbit

Ferret

Small Mammal

Other

What Breed?(Required)

Gender(Required)

Male

Female

Unkown

Altered?(Required)

Yes

Date of Birth(Required)

Color / Markings(Required)

Normal Diet:(Required)

Allergies:(Required)

Current Medication (s):(Required)

Previous health problems:(Required)

Please call the veterinarian office you were using and request that they send your pet's records to us.

Email: petcare@petcarevb.com
Fax: 757-499-6166

Upload your pet's records. (jpg and pdf format only)

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 60 MB.

Do you have any other pets in your home?(Required)

Yes

If "Yes" above, what kind?

Have you or any of your pets been out of the area lately?(Required)

Yes

If "Yes" above, where?

Tell us how you found Pet Care

How did you find us?(Required)

Referral

Our Location

Local Event

Friend

Veterinarian

Online

Website

Who may we thank?(Required)

How did you find us online?(Required)

Facebook

Google

Yahoo

Bing

Yelp

Rescue Group

Professional fees are to be paid at the time services are rendered(Required)

I Agree

Pre-Visit History Questionnaire

Owner Name:(Required)

First Last

Patient Name:(Required)

Reason for Visit?(Required)

Current diet: (Brand, amount fed, frequency)(Required)

Current medications:(Required)

Heartworm/flea prevention: (brand, last time given)(Required)

Changes to appetite or water intake?(Required)

Yes

If "Yes" above please explain.

Vomiting or Diarrhea:(Required)

Vomiting

Diarrhea

Both

None

Coughing or Sneezing:(Required)

Coughing

Sneezing

Both

None

Skin problems: (scratching, redness, hair loss)(Required)

Yes

If "Yes" above please explain.

Trouble getting up? Difficulty with exercise?

Yes

If "Yes" above please explain.

Microchipped:(Required)

Yes

I'm Not Sure

Favorite treat:(Required)

Virginia Veterinary Disclosure Form

Medical Staffing Hours

Monday through Friday: 7:30 am – 7 pm
Saturday: 7 am – 4 pm
Closed on Sundays and Holidays

Please note that we do not have any overnight or holiday hours.

24 hour medical care is available at:

Bay Beach Veterinary Emergency Hospital
2476 Nimmo Parkway, Unit 101
Virginia Beach, VA 23456
Phone: (757) 427-3214

Animals boarding in the facility will be monitored and cared for as needed. If you would like around the clock care for your pet please inform us.

Confirm(Required)

I have read this form and I am aware of the hospital’s staffing procedures.

Pet Care Veterinary Hospital Financial Policy

Financial Policy

We have several payment options available but do not extend credit or offer payment plans. Payment in full is due at time of service. We may require a deposit for major procedures.

We accept: Cash, Check, Bank Credit/Debit Card, MasterCard, Visa, Discover, American Express, Scratch Pay and CareCredit.

Please note: The entire balance of all credit accounts is due and payable in accordance with the terms as stated on the invoice. The parties agree that all payments still owing after the due date may be assessed a service charge at the rate of one and one-half percent (1.5%) per month or eighteen percent (18%) per annum. In addition, in the event of default where it becomes necessary to place this account in the hands of a third party for collection, the undersigned agrees to pay all costs of collection, including reasonable attorney’s fees and court costs.(Required)

I Understand and Accept

Consult Statement for Veterinary Drug Use

Many of the drugs veterinarians prescribe for the treatment of their patients are not approved by the Federal Drug Administration (FDA) for all or any of the animal species and their use is considered “off-label”. However, it is a legal and well-accepted practice for veterinarians to prescribe these drugs. We want you to be aware that while treating patients we may use drugs that have not been approved by the FDA for use in all species.

All information that I have filled out on the client info sheet is current and up to date.(Required)

Yes

I have read, understand and agree to the above Financial Policy and Veterinary Drug Use Statement.(Required)

I Understand and Accept

You may use my pet’s picture on your website or social media pages.(Required)

Yes

Date(Required)

Signature(Required)

CAPTCHA

Name

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