Apple Valley Animal Hospital

1207 Cedar Creek Grade
Winchester, VA 22602

(540)678-0202

applevalleypet.com

 

Client Information

  

New Clients, you will need a Client Information, Vaccination Consent, Advance Directive and Staff Hours form filled out prior to your first appointment! 

Please forward all previous records to avahpets@gmail.com

 

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Client Information Form

OWNER INFORMATION:
Name (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Owners County (required)

Spouse's Name
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Home Phone
Phone TypePhone Number
Cell Phone (required)
Phone TypePhone Number (required)
Driver's License number (if you are writing a check)

Employer

Work Phone
Phone TypePhone Number
Spouse's Employer

Spouse's Work Phone
Phone TypePhone Number
PET INFORMATION
Name (required)

Species (required)

Dog
Cat
Other


If other, what kind?

Breed (required)

Sex/Spayed or Neutered (required)

Female
Female Spayed
Male
Male Neutered


Color (required)

Date of Birth :
(Please give any records you have for your pet to the receptionist.)
Previous Veterinarian

Other medical problems

Important - Read Carefully:
I understand payment is due when services are rendered. If emergency circumstances should arise that I do not pay my bill, I understand that I owe The Apple Valley Animal Hospital for their services. Finance charges will be charged on any unpaid balance at the rate of 2% per month (24% annually). I understand that I will be responsible for all collection fees, court costs and attorney fees, should collection procedures become necessary.
Name of Responsible Party (must be over 18 years old.) (required)

I agree that I have read all of the information provided on this form and that all of the above information I have provided is true. (required)

Yes, I agree


Date (required) :

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