Online Form

New Client Form

Save time during your first appointment! Complete your required new client form online before your visit.

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

You may use the PDF version by clicking the Download Form button and completing the printed form by hand. Please bring the completed PDF form with you for your pet’s first appointment.

Download Form

Owner’s Name *

First

Last

Spouse/Other

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell *

Work

Spouse/Other Cell

Work

WE NEED YOUR E-MAIL ADDRESS! By providing us with your e-mail address, we will be able to send you appointment reminders, vaccine reminders, and you will be able to access your pet’s medical records 24 hours a day. You will also be able to print a wallet card with your pet’s vaccine information to use when you are traveling, taking your pet to the groomer or boarding your pet. This service is complimentary by providing us your e-mail address. You will also be able to receive special coupons and promotions! We will not sell your information or SPAM you.

E-mail Address *

How did you hear about us

Yellow Pages
Sign
Recommendation
Other

If recommended, who can we thank? *

Please list all individuals authorized to request treatment for your pet(s)

Pet Health History

Pet's Name *

Species (dog, cat, other) *

Birthdate *

Sex *

Male
Female
Neutered Male
Spayed Female

Breed *

Color *

Do you have a second pet? *

Previous Veterinarian

I hereby authorize the veterinarians at Churchland Animal Clinic to examine, prescribe for, and treat the above described pet(s). Any animal admitted or hospitalized shall receive the necessary diagnostic tests and treatment to ensure proper medical care. I agree to pay for all services rendered and medications, goods, and supplies when purchased. I understand that a deposit may be required for surgical or medical treatment. All accounts not paid within 30 days will be subject to a late charge of 1 ½% per month (18% per annum) on the unpaid balance and billing charges in the amount of $3.00 per month. In the event of default, the undersigned further agrees to pay any or all collection agency, court costs, and attorney fees in the amount of 33 1/3% of the total due when turned over for collection. These fees are due without any relief whatever from valuation or appraisement laws. This contract extends to all additional pets brought in at a later date. ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. A $35.00 charge is made for all returned checks. *

I have read and agree

I understand the veterinarian hours are from 8am – 12pm and 2pm – 7pm Monday through Thursday, 8am – 12pm and 2pm – 6pm on Friday, and 8am – 2pm on Saturday. I understand that at all other hours, there may not be a veterinarian providing continuous care. By my signature below, I hereby agree to all of the above and acknowledge the receipt of a copy of this agreement (upon request). *

I have read and agree

Signature of Owner or Agent *

Clear Signature

Date

Comment

Online Form

New Client Form

New Client Form

Pet Health History

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Location

Hours

We Provide Local Veterinary Services in Portsmouth, Chesapeake, Suffolk, Norfolk, and surrounding areas.