Registration Form Name* First Last Driver’s license #Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Phone #Cell Phone #*Work Phone #E-mail address* Spouse/Other’s Name First Last Place of EmploymentHow did you hear about us? (please circle one)*Yellow Pages.comPhone BookK9 CarnivalInYourArea.comVetsNearYou.comSPCA WalkComercial/TV/RadioSign (walk-by)FriendIf so then whom?Pet’s Name*Sex*Spayed or neutered?*YesNoBreed*Color*Age*Species*Allergies*Where does your pet sleep?*(inside or outside)Has your pet ever had a professional dental cleaning?*YesNoIf so then when?PREFERRED METHOD TO RECEIVE LAB RESULTS:*E-MAILPHONECALLI HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, OR TREAT ABOVE PET. I ASSUME RESPONSIBILITY FOR ALL CHARGES THAT OCCUR IN THE CARE OF ABOVE PET. I ALSO UNDERSTAND THAT ALL CHARGES MUST BE PAID AT THE TIME OF SERVICES. ( SIGNATURE OF OWNER )*Date* Date Format: MM slash DD slash YYYY Signature*Date* Date Format: MM slash DD slash YYYY Print Name* First Last WitnessPAYMENT POLICY Please be advised that all pets that are not picked up by the closing of any given day will be boarded at the owners’ expense. Pickup time for boarding is 2:00 PM. If pet is picked up after pick-up time then additional charges will apply. Exceptions are Grooming and Doggie Daycare. Drop off time for boarding is Monday, Wednesday, and Friday between 8:00AM and 5:00PM,Tuesday and Thursday between 8:00AM-6:00PM, and Saturday 8:00AM-12:00PM. **Be advised that if pet is not dropped off during drop off times, there is a LATE FEE. Owners must provide proper vaccine records. I understand that if records are not provided, Abbey Animal Hospital will give all required vaccines. Unfortunately due to some credit abusers, PAYMENT IS DUE AT THE TIME THE SERVICE IS RENDERED. As we receive no charitable donations or government subsidy this policy will insure Abbey Animal Hospital will be able to continue to provide quality care to all its patients. PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. We accept cash, Care Credit, and all major credit cards. THERE WILL BE A $25.00 CHARGE FOR FAILURE TO CANCEL APPOINTMENT WITHOUT A FULL 24 HOUR NOTICE. All surgeries must be paid for upon DROPPING OFF your pet. I understand that upon arriving late for a scheduled appointment, there will be a convenience/late fee. In all emergency cases a deposit equal to 50% of estimated treatment costs is required. The balance is due upon completion of treatment. Please feel free to discuss fees for services before those services are performed. A written estimate can be made upon request. Estimates are only an ESTIMATE and not to be considered a final quote. NO CASH REFUNDS. SALES OF ALL medications and prescriptions are final. WE MUST POINT OUT THAT OBTAINING PROFESSIONAL SERVICES KNOWINGLY WITHOUT INTENT OR ABILITY TO PAY, OR WRITING A BAD CHECK CONSTITUTES FRAUD UNDER THE LAWS OF VIRGINIA. I UNDERSTAND THERE WILL BE A $25.00 CHARGE FOR FAILURE TO CANCEL APPOINTMENT WITHOUT A FULL 24 HOUR NOTICE. I have read, understand and shall comply with the above payment policySignature*Date* Date Format: MM slash DD slash YYYY Print Name* First Last WitnessNEW PET QUESTIONAIREPet’s Name*Your Name* First Last Do you have any other pets?*YesNoIf yes, please note how many of each below.CaninesFelinesBirdsReptilesPocketRabbitFerretOther (Please list)When was your pet’s last visit to the vet and what was he/she being seen for?*Has your pet ever had a vaccine reaction to your knowledge?*YesNoIf yes, please list vaccine & treatments received:I acknowledge that my pet is: NOT AGGRESSIVE to my knowledge Food/Water/Toy AGGRESSIVE Cage AGGRESSIVE Animal AGGRESSIVE AGGRESSIVE & WILL BITE ) Is your pet spayed/neutered?*Not to my knowledgeYesIf yes, when did the surgery take place?Untitleda Please check all that apply to your pet’s medical history: Hyperthyroidism Food allergies Has Seizures Hypothyroidism Autoimmune Deficiency Has Arthritis Heart Murmur On special diet for bladder stones Blind Diabetic On special diet for renal failure Deaf Other problemsDoes your pet have any allergies?*None I’m aware ofYes; please list belowIs your pet currently on any medications including heartworm/flea prevention?*YesNoIf yes please listHas your pet had any recent surgeries? If so when and what typeAny other special care instructions you’d like the doctor to know?Advanced DirectiveAt Abbey Animal Hospital, it is our mission to provide your pet with the highest quality medical care. We achieve this by working with you, the client, to determine what is in your pet’s best interest. Sometimes, situations can occur in which a pet may experience sudden cardiac or respiratory arrest. These instances create a situation in which decisions must be made very quickly in regards to the treatment and care of your pet. With this in mind, we want to ensure that we provide your pet with the treatment you feel is appropriate. *I DO want life saving procedures performed on my pet as necessaryI DO NOT want life saving procedures performed on my pet as necessaryPlease keep in mind, if emergency procedures are performed, they will result in additional charges for the treatment or medications that are administered in this circumstance. We will keep this form in your pet’s chart for the life of your pet, and should you decide at any point that you want to change your decision, please let our staff know and we will update it at that time.Pet Name*As the legal owner of above listed pet, I consent to the method of treatment I have chosen above. I will not hold Abbey Animal Hospital or any agents thereof personally or legally responsible for the results of the treatment I have selected. I understand that even if life saving procedures are administered, there is no guarantee of the outcome. I also agree to all charges incurred due to any emergency procedures performed.Signature*Date* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
