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New Patient
Form
Save time during your next appointment! Complete your required forms online from any device at any time before your visit.
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New Patient 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.
Date of Appointment Scheduled
MM slash DD slash YYYY
Name
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First
Last
Any new updates to your phone, email, or address?
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Yes
No
If yes, please write it in.
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Pet's Name
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Age/Date of Birth
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Breed
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Sex
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Male
Neutered Male
Female
Spayed Female
Please upload a photo of your pet to be used as their profile picture.
Max. file size: 50 MB.
Secondary Caregiver's Name
First
Last
Relationship
Secondary Caregiver's Phone
Secondary Caregiver's Email
Would you like this secondary caregiver's E-mail to be CC'd on communications?
Yes
No
I understand that the Doctors and staff of the Williamsburg Veterinary Clinic are dedicated to providing me and my pet/s with the best diagnostic/ therapeutic and preventive care. The Williamsburg Veterinary Clinic works diligently to provide appointment times with as little wait time as possible. Estimates for services to be performed are available upon request. I acknowledge that the hospital's attempt to provide accurate estimates will, at times, require adjustment due to unforeseen factors or events. I accept full responsibility for fees that go beyond the original estimate, should I not be found to be available for consent.
(Required)
I have read and understand
The Williamsburg Veterinary Clinic loves making pets Facebook Famous and Instagram stars! Please give us your permission to share your pet(s) image and story on social media, our website, and other marketing materials. Your personal information will never be shared.
(Required)
I give permission to share my pet(s) image and story
I do not want my pet(s) image and story shared
I understand that payment is required in full at the time of service, and I may pay with credit, debit, CareCredit, or cash. Should I fail to inform the office with reasonable notice that I will not make my appointment, Williamsburg Veterinary Clinic maintains the right to charge a fee to my account of $105.00 Finally, I understand that only I am in a position to authorize care of my pet/s. I will not send minors or third parties as my agent. I will list below the responsible parties (co-owners) of the pet/s on my account.
(Required)
I understand that payment is required in full at the time of service, and I may pay with credit, debit, CareCredit, or cash.
Should I fail to inform the office with reasonable notice that I will not make my appointment, Williamsburg Veterinary Clinic maintains the right to charge a fee to my account of $105.00
Finally, I understand that only I am in a position to authorize care of my pet/s. I will not send minors or third parties as my agent. I will list below the responsible parties (co-owners) of the pet/s on my account.
I have read and understand
How did you hear about us? We'd like to thank them!
If by word of mouth or friend, please write their name.
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Date
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