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Owner

Title

Mr.
Mrs.
Ms.

Owner Name *

First

Middle

Last

Home Address *

Address Line 1

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City

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Zip Code

Cell Phone Number *

Home or Secondary Number

Email Address *

Driver’s License or I.D. Card Number *

Expiration Date *

Partner/Spouse/Co-Owner

Title

Mr.
Mrs.
Ms.

Partner/Spouse/Co-Owner Name

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Last

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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? *

Former Veterinary Clinic for your pet(s)

Name

Phone Number

Email

Pet Information

Name *

Age/Birthday *

Sex *

Male
Female

Species (dog, cat, etc.) *

Breed *

Color *

Spayed/neutered? *

Yes
No

Medications

Medical History

Additional Pet Information

Name

Age/Birthday

Sex

Male
Female

Species (dog, cat, etc.)

Breed

Color

Spayed/neutered?

Yes
No

Medications

Medical History

Online Pharmacy

At Farmers 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 Farmers 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 Care Credit 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 doctor 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 *

Audio Recordings

All appointments will be audio recorded to ensure accurate records and quality service. By proceeding with services, you acknowledge and consent to these recordings. Recordings are kept confidential and used only for internal purposes,unless disclosure is required by law.

Signature of Owner *

Clear Signature

Date *

Appointment & Cancellation Policy

New Client Deposit

- A $70 deposit is required to schedule your first appointment.

- This deposit will be applied toward your pet's exam.

- Your deposit will be refunded or credited if you cancel with at least 24 business hours' notice.

- Late cancellations may reschedule once and keep the original deposit.

- If the rescheduled appointment is missed or canceled with less than 24 business hours' notice, the deposit is forfeited and a new deposit is required.

- Exceptions may be made for emergencies if you contact us.

Missed Appointments & Late Cancellations

- After more than three missed appointments or cancellations made with less than 24 business hours' notice within one year, a $70 deposit is required for future appointments.

- The deposit will be applied toward the exam.

- One late reschedule is allowed while keeping the deposit.

- If the rescheduled appointment is missed or canceled late, the deposit will be forfeited.

- After one year without additional missed appointments, the deposit requirement may be removed. The policy restarts if another missed appointment occurs.

- Exceptions may be made for emergencies if you contact us.

Surgical Procedures

- A $250 deposit is required to schedule surgery.

- The deposit will be applied toward the procedure cost.

- If surgery is canceled with at least 72 business hours' notice, the deposit will be credited.

Why This Policy Matters

Missed and last-minute appointments prevent us from caring for other pets in need. This policy helps us reduce unused appointment times, provide timely care for more patients, and ensure our schedule remains available for families who need us.

Signature of Owner *

Clear Signature

Date *

Social Media Consent Form

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.

Pet’s Printed Name *

Owner’s Printed Name *

Owner’s Signature *

Clear Signature

Date *

Online Form

New Client Form

New Client Form

Owner

Partner/Spouse/Co-Owner

Former Veterinary Clinic for your pet(s)

Pet Information

Additional Pet Information

Online Pharmacy

Statement of Ownership

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

Audio Recordings

Appointment & Cancellation Policy

New Client Deposit

Missed Appointments & Late Cancellations

Surgical Procedures

Why This Policy Matters

Social Media Consent Form

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Location

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Business Hours

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