New Client Form

Name

First Name

Last Name

Driver’s License # & Issuing State

Owner’s Date of Birth

Phone

Street Address

State

City

Zipcode

Email

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Patient Information

Patient Name

Species

Breed (If Known)

Color

Sex

Patient Date of Birth or Age

Special Identification (Markings, Microchip, etc.)

Name of Previous Veterinarian (if any)

Phone of Previous Veterinarian

If you have more than one pet, please include their information below

Patient Name

Species

Breed (If Known)

Sex

Color

Patient DOB or Age

Agreements and Disclosures

How did you hear about us?

If personal referral, is there someone we can thank for this referral?

I give Bay Beach Veterinary Hospital permission to use my pet’s name, story, and images (photos, video, or other media) for social media, marketing, and educational purposes.

I understand all fees are due at the time services are rendered and I agree to pay the balance in full. If not paid in full, I agree to pay all costs associated with collection. I agree and understand that by typing my name below, all electronic signatures are the legal equivalent of my signature and I consent to be legally bound to this agreement.

I understand

Hospital Policies

All businesses, especially medical offices, have regulations that guide their daily activities. Some can feel very inconvenient at times, but please understand that they are necessary. If you feel that you have been unnecessarily inconvenienced or that your pet’s health was not our priority, please contact Notasha Harris, the Practice Manager. She will return your call as soon as practical.

Client-Doctor-Patient Relationship

We are unable to dispense or prescribe any medications without a current client-doctor-patient relationship. This relationship only exists when your pet has been examined by one of our veterinarians annually. PLEASE NOTE – Our day and urgent care services, while affiliated and housed under the same roof, are two separate entities. The client-doctor-patient relationship does not carry over between the two.

Medications

Heartworm prevention can be sold or prescribed if your last purchase date was within the period covered by the last box of medication purchased and your pet’s heartworm test and physical examination are current. If there has been a lapse of six months or more, we will require a heartworm test before it can be dispensed. This is for the safety of your pet.

Chronic medication can be refilled for not more than one year. A physical exam must be performed by one of our veterinarians annually to continue to refill. Additionally, some medications require semi-annual exams and/or semi-annual and annual lab testing. If your pet is on one of these medications, refills will not be filled for patients with past due lab work. Please consult with the veterinarian for additional information.

Written scripts will be provided to any client by request to fill at a licensed pharmacy as long as the prescription conforms to our own dispensing guidelines.

Office Procedures

We are open 8:00 am to 7:00 pm Monday, Tuesday and Thursday, 8:00 am to 6:00 pm on Wednesday and 8:00 am to 5:00 pm on Friday.

For the safety of your pet as well as others in the building, we require that all pets be either on a fixed lead or leash or in a carrier. Not only does this protect against unexpected snaps from other patients in the waiting room, it also limits the contact your pet may have with sick pets.

Please help us keep your pets safe!

I have read and understand the hospital policies outlined above, and I agree to comply with them.

I understand

Virginia Veterinary Hours Disclosure

Pursuant to a State of Virginia Law, Act 54.1 – 3806.1, effective July 1, 1991, veterinary practices admitting patients to their facilities must disclose hours of continuous medical care. Bay Beach Veterinary Hospital has business and medical staffing hours as follows:

Monday, Tuesday, and Thursday from 8:00 am to 7:00 pm
Wednesday from 8:00 am to 6:00 pm
Friday from 8:00 am to 5:00 pm
December 24th: 8:00 am to 12:00 pm (if Monday-Friday)
December 31st: 8:00 am to 5:00 pm (if Monday-Friday)

This facility is closed on weekends and major holidays. Therefore, this is to inform you that we have no in-house, on-duty continuous medical staff during the following times:

Overnight, from closing time (as above) to opening time at 8:00 am
Weekends, from closing time Friday at 5:00 pm to Monday at 8:00 am
Holidays, from closing time before the holidays (as above) to opening time the day after the holiday at 8:00 am.

If 24-hour continuous care is desired, owners may transfer their pets to an animal emergency clinic of their choice during the hours when our clinic is closed.

By submitting this form, I acknowledge that I have read and am aware of the staffing hours at Bay Beach Veterinary Hospital.

I acknowledge that I have read and am aware of the staffing hours at Bay Beach Veterinary Hospital.

I understand

Name

First Name

Last Name

Patient Information

If you have more than one pet, please include their information below

Agreements and Disclosures

Hospital Policies

Virginia Veterinary Hours Disclosure

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