Client Information Form

Client Information
Name
First Last
VA Driver's License/ID#
Address
Street Address Address Line 2 City State Zip
Home Phone
Cell Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Emergency Contact
First Last
Emergency Contact Phone
Pet Information
Name
Age or DOB
Reproductive Status:
Breed
Color
Most recent rabies vaccine
Comments
Referring Clinic Information
Clinic
Referring Doctor
Reason for Referral
Method of Payment
Payment
- Cash
- Check
- Debit Card
- VISA
- MasterCard
- Discover
- AmEx
- CareCredit
Row Start
Consent*
I agree and understand that payment is expected in full at the time services are rendered.
Cash, credit cards and local checks are accepted. If surgery is needed, and I agree to my pet’s surgery, a 50% deposit of the estimated surgical expenses will be required when I leave my animal with BAVS for the recommended procedure, with the balance to be paid in full when my pet is discharged into my care. I further agree that I am responsible for any collection or attorney fees that may result from default on my account. *If using CareCredit for full or partial payment, please ask our receptionist about the plans we offer and make certain you understand the terms of payment.
Column Break
Date*
Row End
CAPTCHA

Client Information