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Owner Information

Title

Mr.
Mrs.
Ms.

Owner Name *

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Middle

Last

Home Address *

Address Line 1

Address Line 2

City

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Zip Code

Cell Phone Number *

Home or Secondary Number

Email Address *

Co-Owner Information

Title

Mr.
Mrs.
Ms.

Partner/Spouse/Co-Owner Name

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Middle

Last

Phone

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What is your preferred form to receive communication with us?

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If other, please specify: *

How did you hear about us?

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Whom can we thank? *

Previous Veterinary Clinic Information

Previous Clinic's Name

Previous Clinic's Phone Number

Previous Clinic's Email

Pet Information

Pet's Name *

Age or Birthday *

Sex *

Male
Female

Species (dog, cat, etc.) *

Breed *

Color *

Is your pet spayed or neutered? *

Yes
No

Medications

Medical History

Additional Pet Information

Pet's Name

Age or Birthday

Sex

Male
Female

Species (dog, cat, etc.)

Breed

Color

Is your pet spayed or neutered?

Yes
No

Medications

Medical History

Online Pharmacy

At Farmer's Veterinary Hospital, we are committed to creating the best possible experience for our clients and pet patients. As part of that commitment, we would like to make it as easy as possible for our clients to obtain all of the preventatives and medications that their pets need. Our exclusive on-line pharmacy allows for you to order any flea/tick/ heartworm preventatives and medications for your pet, and have them delivered directly to your home. In order to initiate this service, we can provide you with all the information you need to create an account with this service. You can also visit our web site for more information. *

Yes – I would be interested in this service
No Thanks

Statement of Ownership

I certify that I am the true owner and/or agent of the above animal(s), and have the authorization to consent to treatment if and when it is needed. *

I have read and accept.

Signature *

Clear Signature

Date *

Professional Fees are to be Paid at the Time Services are Performed

In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians and support staff of Farmer's Veterinary Hospital to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary
It is understood that an estimate of charges will be given upon request for services. No guarantee or assurance can be made as to the results that may be obtained for services provided.
I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur.

For your convenience we accept cash, MasterCard, Visa, American Express or Discover Card. We also accept CareCredit and ScratchPay.

Signature of Owner *

Clear Signature

Date *

We will do everything in our power to accommodate your schedule at all times. If you cannot make it to any appointments in the future, please call as soon as possible to reschedule or cancel the appointment. PLEASE NOTE that if you don't call ahead of time to reschedule or cancel more than 3 times in a 12 month period, you may be required to leave a non-refundable down deposit for future appointments. Removal of deposit requirement will be at the discretion of Farmer's Veterinary Management.

Peanut Law

In compliance with the Code of Virginia, we are required to inform you of hours of operation with a veterinarian in the building. Monday-Friday 9am-6pm. The office is closed Saturday and Sunday. In case of emergency, we would advise the patient be taken to an urgent care or emergency facility

Signature of Owner *

Clear Signature

Date *

Social Media Consent

I hereby give Farmer's Veterinary Hospital permission to take photographs and videos of me and my pet for the purpose of posting on Farmer's Veterinary Hospital’s Facebook, Instagram, Indeed, and clinic website.
I hereby release and discharge Farmer's Veterinary Hospital from any and all claims arising out of use of the photos.

Farmer's Veterinary Hospital has my permission to use: (Check One)

Only my pet’s name(s)
My pet’s name(s) and my last name
My pet’s name(s) and my first and last name
I wish for neither me or my pets photos or videos to be used.

In signing this consent, I give authorization to use my name and my pet’s name as printed below.

By signing this consent form, I confirm that I do not authorize the use of photos or videos of myself or my pet.

Pet’s Printed Name *

Owner’s Printed Name *

Owner’s Signature *

Clear Signature

Date *

Online Form

New Client Form

New Client Form

Owner Information

Co-Owner Information

Previous Veterinary Clinic Information

Pet Information

Additional Pet Information

Online Pharmacy

Statement of Ownership

Professional Fees are to be Paid at the Time Services are Performed

Social Media Consent

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