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Fill out this form, print it out, and bring it in with you to your first visit. Madison Companion Animal Hospital 2658 South Seminole Trail, Madison, VA 22727 Phone: 540-948-6876 Email: mcah@verizon.net New Client Form Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following: CLIENT INFORMATION Date___________ Client ID _________ (office use) Name ______________________________________ Driverēs License No. _____________________ Spouse/Other ________________________________ Driverēs License No. _____________________ Address____________________________________________________________________________ City ______________________________________State _______________Zip__________________ Home Phone _____________________Work Ph. __________________ Cell Ph __________________ Place of Employment_______________________________ Email ____________________________ Spouse/Other/Emergency Phone Number _________________________________________________ All Fees Are Due At The Time Services Are Rendered. Please indicate choice of payment. ____Cash ____Check ____Credit Card ____Care Credit How did you become aware of our clinic? ڤLocal Yellow Pages ڤCharlottesville Yellow Pages ڤ ڤ Referral from someone we may thank? _______________________PATIENT (PET) INFORMATION 1. Name ____________________________ Circle One: Dog Cat Other___________________ Breed _________________________ Color _______________Date of Birth or Age:____________ Circle One: Male Female Is your pet spayed or neutered? Circle One: YES NO Additional Info/Allergies:___________________________________________________________ 2. Name ____________________________ Circle One: Dog Cat Other___________________ Breed _________________________ Color _______________Date of Birth or Age:____________ Circle One: Male Female Is your pet spayed or neutered? Circle One: YES NO Additional Info/Allergies:___________________________________________________________ 3. Name ____________________________ Circle One: Dog Cat Other___________________ Breed _________________________ Color _______________Date of Birth or Age:____________ Circle One: Male Female Is your pet spayed or neutered? Circle One: YES NO Additional Info/Allergies:___________________________________________________________
PLEASE READ AND SIGN. Veterinary Facility Disclosure Statement: The Virginia General Assembly has enacted Code Number 54.1-3806, which demands that all animal medical care facilities state to clients/guardians, that there is no staffing of the hospital after the doctors and staff leave the premises at the end of our working day. At Madison Companion Animal Hospital the doctors and staff leave this hospital after 6 pm Monday through Friday and return at 7:30 am the following working day. On Saturday morning the hospital is staffed from 8 am to noon. There is continuous medical care on Monday through Friday 7:30 am to 6 pm, and on Saturday from 8 am to 12 noon. The hospital is equipped with a fire and burglar alarm and a staff member lives on the hospital property, which meets the high standards set by the American Animal Hospital Association, to which we belong. I have read the above and understand the hospital staffing hours. Signature of owner or Agent ______________________________________________ Date __________________________
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