Client Information

Owner Name *

First

Last

Email *

Home

Cell *

Work

Co-Owner/Spouse

First

Last

Spouse Cell

Spouse Work

Please check which phone you would like us to use as your primary contact number. *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please check if you would like to receive any of the following via email?

Vaccine Reminders & Information Alerts
Newsletter

Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Referred by

Sign/Drove By
Website
Internet Search through
Personal Referral

Personal Referral by: *

Pet Information

Pet's Name *

Species (dog, cat, bird, etc.) *

Breed *

Color *

Sex *

Female
Female Spayed
Male
Male Neutered

Birth Date or Age *

Age Pet Was Obtained *

Pet Obtained From *

Shelter
Friend
Breeder
Rescue group

Previous Vet:

Please list any previous vet where we may obtain vet records from.

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, bird, etc.) *

Breed *

Color *

Sex *

Female
Female Spayed
Male
Male Neutered

Birth Date or Age *

Age Pet Obtained *

Pet Obtained From *

Shelter
Friend
Breeder
Rescue group

Previous Vet:

Please list any previous vet where we may obtain vet records from.

Examination & Treatment Authorization And Assumption Of Financial Responsibility

To maintain our high quality of care, Hartwood Animal Hospital is dependant upon payment of services at the time they are rendered. For this reason the hospital does not extend credit (bill). We accept cash, check (w/ID), VISA, & Mastercard. We will be glad to provide a treatment plan for services at any time. A deposit will be required prior to starting treatment for surgical and hospitalized patients. *

I have read and agree to the above statement

I, the undersigned, authorize the Doctors and staff of Hartwood Animal Hospital to examine and treat the above described pet(s) and to administer any medical, surgical treatments and/or tests, including sedation or anesthesia which is considered necessary based on findings during the course of examinations. I understand that any treatments performed will be with my full knowledge and consent except in emergency situations. *

I have read and agree to the above statement

I assume responsibility for all charges incurred for services rendered to the patient. I understand there is a $35.00 service charge for returned checks and that after thirty (30) days unpaid accounts may accrue interest at the rate of 1.5% per month (18% per annum) monthly. If collection action is necessary on this account, I agree to pay all costs of collection of 33% of the balance owed plus attorney fees, whether or not the suit is filed. The parties agree to the exclusive venue and jurisdiction of Stafford County, Virginia, for all matters arising from this agreement. *

I have read and agree to the above statement

Authorized Owner or Agent Signature (must be 18 years or older) *

Clear Signature

Date *

New Client Form

New Client Form

Client Information

Pet Information

Examination & Treatment Authorization And Assumption Of Financial Responsibility

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