New Patient Form

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I am a New Patient
New patients are asked to complete this form prior to first appointment. This allows our staff to prepare your account files prior to your visit and saves you time in our office.

New Client, Submitting Form for First TimeExisting Client, Adding Pet

Date of Next Appointment

Name

Spouse's Name

Street Address

City, State, Zipcode

Home Phone

Work Phone

Cell Phone

Date of Birth

Place of Employment

Driver's License # (must have to pay by check)

How did your hear about us?

Personal recommendation (Whom may we thank?)

Patient #1 Name

Patient #1 Type

Patient #1 Breed

Patient #1 Date of Birth

Patient #1 Color

Patient #1 Sex

Patient #1 Date of Last Heartworm Prevention

Patient #1 Previous Veterinarian
Please supply name, hospital name, phone number.

Patient #1 is:

Patient #1 Previous Illnesses or Surgeries? When?

Patient #1 Special diet or medications?

Patient #2 Name

Patient #2 Type

Patient #2 Breed

Patient #2 Date of Birth

Patient #2 Color

Patient #2 Sex

Patient #2 Date of Last Heartworm Prevention

Patient #2 Previous Veterinarian
Please supply name, hospital name, phone number.

Patient #2 is:

Patient #2 Previous Illnesses or Surgeries? When?

Patient #2 Special diet or medications?

Patient #3 Name

Patient #3 Type

Patient #3 Breed

Patient #3 Date of Birth

Patient #3 Color

Patient #3 Sex

Patient #3 Date of Last Heartworm Prevention

Patient #3 Previous Veterinarian
Please supply name, hospital name, phone number.

Patient #3 is:

Patient #3 Previous Illnesses or Surgeries? When?

Patient #3 Special diet or medications?

Additional Comments
If you have any additional information you want to provide for any of your pets, please include here.

Acknowledgement of Office Hours
The Ashburn Village Animal Hospital is not staffed 24 hours a day. If your pet is here over night or on Sunday, there will not be an attendant present. The hospital is staffed: Mon and Tues: 7am to 8pm; Wed and Thurs: 7am to 7pm; Fri: 7am to 6pm; Sat: 8am to 3pm

Click for YES I have read and understand AVAH does not have 24 hour staffing.

Payment Policy
**Payment is expected at the time services are provided** This hospital accepts: VISA, MasterCard, Discover, American Express, Checks and Cash. A $25.00 service fee will be applied to all returned checks. Balances over 30 days will be subject to an interest rate of 2% per month. All collection agency and attorney fees necessary to collect an overdue balance will be added to the bill. Deposits may be required for major medical/surgical cases, or trauma and emergency work where hospitalization is required. All services must be paid in full before the animal can be released. Please note our no-show and late policies. The Ashburn Village Animal Hospital is not staffed 24 hours. If your pet is here overnight, there will not be an attendant present. This hospital is staffed: Monday and Friday 7am to 7pm, Tuesday through Thursday 7am to 8pm and Saturday 8am to 3pm.

Click for YES I read and understand the Payment Policy

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Resources

We are located:
44110 Ashburn Shopping Plaza #172
Near the Ashburn Sports Pavilion
703-729-0700

Emergency Info

In case of emergency contact:

Hope Center
Vienna,VA
703-281-5121

The Life Center
Leesburg, VA
703-777-5755