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IF YOU ARE NEW TO OUR HOSPITAL,
PLEASE CONTACT US BY PHONE OR EMAIL
TO SET UP AN APPOINTMENT
BEFORE
COMPLETING THIS FORM
***THANK YOU***
New Client Form
Owner Information
Name
*
First
Last
Preferred Pronoun:
She/Her/Hers
He/Him/His
They/Them/Their
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Work Phone
Cell Phone
Email
Co-Owner Name
First
Last
Home Phone
Work Phone
Cell Phone
Email
Relationship to Owner:
Spouse
Significant Other
Relative
Friend
Other
Please specify other:
Preferred phone number for CALLS:
Preferred phone number for AUTOMATED TEXT REMINDERS:
Preferred email address for AUTOMATED EMAILS:
Alternate Contact:
First
Last
Phone
Alternate Contact:
First
Last
Phone
Previous Veterinary Clinic:
Pet Information
Name
Birthdate or Age
Species
Dog
Cat
Breed
Colour
Sex
Male
Female
Neutered/Spayed
Yes
No
Do you have any other pets in your household to register with our hospital?
Yes
No
Name
Birthdate or Age
Species
Dog
Cat
Breed
Colour
Sex
Male
Female
Neutered/Spayed
Yes
No
Do you have any other pets in your household to register with our hospital?
Yes
No
Name
Birthdate or Age
Species
Dog
Cat
Breed
Colour
Sex
Male
Female
Neutered/Spayed
Yes
No
How did you hear about us? (please check all that apply)
Individual-please let us know who so we can thank them!
Online search/website
Social media (Facebook, Instagram)
Driving by
Another clinic
Other
Please specify individual/other
Do you, or anybody in your house, have any allergies to antibiotics or other medications?
Yes
No
If yes, please specify
Professional fees are due at the time of services rendered. For payment we accept Cash, Debit, VISA & Mastercard. We regret that we DO NOT ACCEPT CHEQUES.
I hereby authorize Williamsburg Veterinary Hospital (WVH) to send correspondence to the address, email and fax number provided on this form and to leave messages either with a machine or with a person at the phone number(s) provided on this form.
I hereby consent to my personal information and/or medical information for any of my pets (present or future) being disclosed when necessary for continuity of patient care. This includes releasing or obtaining of medical records to or from any relevant veterinary hospital(s).
I hereby consent to any of my present or future pets’ likeness (photo or video) being used for WVH marketing purposes including use on our website or social media page(s) or other online forum.
Signature of Owner or Responsible Agent
*
Date
*
Date Format: MM slash DD slash YYYY
Δ
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New Clients
New Client Welcome Form
Take a tour
Pet Insurance Program
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About Us
Meet Our Team
Services
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
News
Contact Us
Locations & Hours
Download Our App
SHOP ONLINE
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