804-518-8541
[email protected]
X
X
Home
About
Our Story
Our Team
Reviews
Photo Gallery
Services
Resources
Online Forms
Online Pharmacy
Contact
Appointment
Select Page
online forms
New Client Form
Get Started
New Client Form
Save time during your next appointment! Complete your
new client form
online from any device at any time before your visit.
Please enable JavaScript in your browser to complete this form.
Client Information
Your Full Name
*
First
Last
Spouse’s Full Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
Layout
Home Phone Number
Cellular Number
Work Number
Current Employer
Employer’s Address
Emergency Contact
*
Emergency Phone Number
Patient Information
Pet's Name
*
Pet's Birth Date/Age
*
Species
*
Breed
*
Color
*
Weight
*
Sex
*
Male
Male Neutered
Female
Female Spayed
Previous Veterinarian
*
Previous Medical History
*
Does your pet have a microchip identification?
*
Yes
No
History Information
Concern for Today’s visit
*
When did your pet last eat?
What diet are your currently feeding your pet?
Any coughing or sneezing?
*
Yes
No
If yes, how often?
Any vomiting or diarrhea?
*
Yes
No
If yes, how often and the consistency of the stool / vomitus?
Is your pet taking heartworm prevention?
*
Yes
No
What product and when was it last given?
Is your pet taking flea and tick prevention?
*
Yes
No
What product and when was it last given?
Is your pet currently taking any medications?
*
Yes
No
Please list all medication your pet is currently on:
Do you need any refills?
*
Yes
No
Which medications do you need refills for?
After examination by the doctor, may we proceed with tests and/or treatments?
*
Proceed with tests and/or treatments deemed necessary for the best care
Call me for approval before completing any services to my pet.
If the vetXpress staff finds a live flea on your pet, we will administer flea control to your pet at your expense.
*
I have read and understand
How did you hear about us?
Referral from a friend
Our Website
Facebook
Newspaper
Other
Please Note:
• If your pet is being dropped off for an appointment, we require an 60% deposit during check in and the remained to be paid upon release of you pet from the hospital.
• We accept cash, VISA, MASTERCARD, and DISCOVER.
•We accept checks only from established clients.
• We must have a copy of a valid driver’s license on file for each client.
• We accept CareCredit.
• All fees are due at the time services are rendered.
By signing below,
*
I understand and agree to the above terms and verify that all information that I have provided is correct and current.
Layout
Signature
*
Clear Signature
Date
*
Submit
