Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

Note: All necessary forms and records are required prior to your visit

PRIMARY OWNER INFORMATION

ARE YOU A NEW CLIENT?(Required)

LAST NAME(Required)

FIRST NAME(Required)

TITLE

ADDRESS(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

PRIMARY PHONE

CELL(Required)

WORK

EMAIL ADDRESS(Required)

BEST CONTACT METHOD?(Required)

OCCUPATION(Required)

EMPLOYER(Required)

SPOUSE / CO-OWNER

LAST NAME

FIRST NAME

TITLE

PRIMARY PHONE

CELL

WORK

BEST CONTACT METHOD?

RELATIONSHIP TO OWNER

HOW DID YOU HEAR ABOUT US?

PLEASE SELECT ONE(Required)

REFERRAL

WHO MAY WE THANK? (please specify)

INTERNET

DROVE BY HOSPITAL

OTHER (please specify)

WHO CAN WE THANK FOR REFERRING YOU TO US?

PLEASE SPECIFY HOW YOU FOUND OUR VETERINARY HOSPITAL

PET INFORMATION

HOW MANY PETS ARE YOU CHECKING IN?(Required)

PET #1

NAME(Required)

BIRTH DATE(Required)

MM slash DD slash YYYY

ANY MAJOR HEALTH ISSUES OR PREVIOUS SURGERIES?(Required)

WHAT DIET DO YOU FEED YOUR PET?(Required)

IS YOUR PET ON ANY MEDICATIONS INCLUDING HEARTWORM PREVENTION AND/OR FLEA AND TICK CONTROL?(Required)

NAME OF MEDICATION

SPECIES(Required)

CAT

DOG

OTHER (please specify)

SEX(Required)

MALE

FEMALE

DATE OF APPOINTMENT(Required)

MM slash DD slash YYYY

PLEASE SPECIFY OTHER

SPAYED/NEUTERED(Required)

YES

IS YOUR PET MICROCHIPPED?(Required)

YES

BREED(Required)

COLOR(Required)

MARKINGS(Required)

IS THERE ANYTHING ELSE WE SHOULD KNOW ABOUT YOUR PET INCLUDING BOTH MEDICAL AND BEHAVORIAL ISSUES?(Required)

IS YOUR PET ON ANY MEDICATIONS? IF YES, PLEASE LIST ALL MEDICATIONS.

PET #2

PET #2: NAME(Required)

PET #2: BIRTH DATE(Required)

MM slash DD slash YYYY

PET #2: ANY MAJOR HEALTH ISSUES OR PREVIOUS SURGERIES?(Required)

WHAT DIET DO YOU FEED YOUR PET?(Required)

PET #2: IS YOUR PET ON ANY MEDICATIONS INCLUDING HEARTWORM PREVENTION AND/OR FLEA AND TICK CONTROL?(Required)

PET #2: NAME OF MEDICATION

PET #2: SPECIES(Required)

CAT

DOG

OTHER (please specify)

PET #2: SEX(Required)

MALE

FEMALE

PET #2: DATE OF APPOINTMENT(Required)

MM slash DD slash YYYY

PET #2: PLEASE SPECIFY OTHER

PET #2: SPAYED/NEUTERED(Required)

YES

PET #2: IS YOUR PET MICROCHIPPED?(Required)

YES

PET #2: BREED(Required)

PET #2: COLOR(Required)

PET #2: MARKINGS(Required)

PET #2: IS THERE ANYTHING ELSE WE SHOULD KNOW ABOUT YOUR PET INCLUDING BOTH MEDICAL AND BEHAVORIAL ISSUES?(Required)

PET #2: IS YOUR PET ON ANY MEDICATIONS? IF YES, PLEASE LIST ALL MEDICATIONS.

PET #3

PET #3: NAME(Required)

PET #3: BIRTH DATE(Required)

MM slash DD slash YYYY

PET #3: ANY MAJOR HEALTH ISSUES OR PREVIOUS SURGERIES?(Required)

WHAT DIET DO YOU FEED YOUR PET?(Required)

PET #3: IS YOUR PET ON ANY MEDICATIONS INCLUDING HEARTWORM PREVENTION AND/OR FLEA AND TICK CONTROL?(Required)

PET #3: NAME OF MEDICATION

PET #3: SPECIES(Required)

CAT

DOG

OTHER (please specify)

PET #3: SEX(Required)

MALE

FEMALE

PET #3: DATE OF APPOINTMENT(Required)

MM slash DD slash YYYY

PET #3: PLEASE SPECIFY OTHER

PET #3: SPAYED/NEUTERED(Required)

YES

PET #3: IS YOUR PET MICROCHIPPED?(Required)

YES

PET #3: BREED(Required)

PET #3: COLOR(Required)

PET #3: MARKINGS(Required)

PET #3: IS THERE ANYTHING ELSE WE SHOULD KNOW ABOUT YOUR PET INCLUDING BOTH MEDICAL AND BEHAVORIAL ISSUES?(Required)

PET #3: IS YOUR PET ON ANY MEDICATIONS? IF YES, PLEASE LIST ALL MEDICATIONS.

EMERGENCY TREATMENT

IN THE EVENT OF AN EMERGENCY, DO YOU AUTHORIZE TREATMENT OF YOUR PET(S) IF EVERY ATTEMPT TO CONTACT YOU WAS UNSUCCESSFUL?(Required)

INITIAL(Required)

PREVIOUS VETERINARIAN

WHAT IS THE NAME OF YOUR PREVIOUS VETERINARIAN?(Required)

PREVIOUS VETERINARIANS PHONE NUMBER?

WOULD YOU LIKE YOUR PET’S MEDICAL HISTORY TRANSFERRED TO OUR HOSPITAL?(Required)

INITIAL(Required)

Please upload any vet records if applicable

Max. file size: 50 MB.

AUTHORIZATION

PREFERRED PAYMENT METHOD FOR TODAY’S VISIT(Required)

SOCIAL MEDIA CONSENT FORM

I here by absolutely and irrevocably authorize Quioccasin Veterinary Hospital to use, publish, reuse, republish, distribute, disseminate, or otherwise make publicly available, photos or videos taken of my pet, their patient, boarder, and/or grooming attendee. By checking this box, I waive any and all rights to approve or otherwise review any uses of the aforementioned photographs or videos. I am a legally competent adult of full legal age and have the right to contract in my own name. I have read this document thoroughly and understand the entirety of its contents in full.

Social Media Consent Form(Required)

I AGREE

OPERATING HOURS DISCLOSURE

Code of Virginia

§ 54.1-3806.1. Disclosure forms required. Any animal medical care facility in the Commonwealth, excluding those facilities dealing with livestock, as defined in § 3.796.66, 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. 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. Signed disclosure forms shall be kept on file by all such facilities.

Virginia Veterinary Disclosure Form

Quioccasin Veterinary Hospital has business and medical staffing hours as follows: Monday – Friday: 8:00am – 6:00pm Saturday: 8:00am – 12:00pm Sunday: Closed. Our hospital may also experience shortened hours or be closed on major holidays. Continuous staffing is not provided during the hours this facility is closed.

Patients requiring continuous monitoring and medication treatment (i.e., intensive care) at times of non-continuous staffing by this facility can be transferred by the owner or their legal agent to a licensed veterinary emergency and medical center, where after hours staffing is provided. Any expenses incurred at that hospital will be the responsibility of the owner.

Operating Hours Disclosure(Required)

I AGREE

I, THE UNDERSIGNED, AND OWNER OR AUTHORIZED AGENT OF THE ABOVE MENTIONED PETS, DO HEARBY AUTHORIZE QUIOCCASIN
VETERINARY HOSPITAL TO PERFORM SUCH EXAMINATIONS, DIAGNOSTIC TESTS AND TREATMENTS AS NECESSARY. I FURTHER AGREE TO BE
FINANCIALLY RESPONSIBLE FOR ALL COSTS FOR SUCH PROCEDURES AND TREATMENTS. I UNDERSTAND THAT FULL PAYMENT IS DUE AT THE
TIME SERVICES ARE RENDERED. FAILURE TO PAY BILLS ON TIME MAY RESULT IN BILLING, FINANCE CHARGES AND/OR COSTS OF ANY
COLLECTION FEE INCURRED.

FULL NAME(Required)

TODAY'S DATE(Required)

MM slash DD slash YYYY

SIGNATURE

New Client Registration Form

PRIMARY OWNER INFORMATION

SPOUSE / CO-OWNER

HOW DID YOU HEAR ABOUT US?

PET INFORMATION

PET #1

PET #2

PET #3

EMERGENCY TREATMENT

PREVIOUS VETERINARIAN

AUTHORIZATION

SOCIAL MEDIA CONSENT FORM

OPERATING HOURS DISCLOSURE

Code of Virginia

Virginia Veterinary Disclosure Form