Animal Hospital of Ivy Square, Charlottesville, Virginia, 295- VETS

434.295.VETS (8387)

2125 Ivy Road
Charlottesville, VA 22903

A HEALTHY PET IS A  HAPPY PET!




HOURS

Monday -  8am - 6pm
Tuesday - 8am - 6pm
Wednesday - 8am - 6pm
Thursday - 8am - 8pm
Friday - 8am - 6pm


 


New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
How did you hear about us? Please give name if one of our clients so we may thank them.

Pet's Name (required)

Age: Years, Months

Type of Pet (required)
Canine
Feline
Avian
Exotic
Other
Breed:

Sex: (required)
Male
Female
Neutered/Spayed
Neutered
Spayed
Are your pet's vaccines current? :
Do you have your pet's medical records? Is yes, bring with you to the appt. :
Medical records at another Veterinary Practice?
Yes
No
Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No
Would you like us to call you for your appointment?
Yes
No
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Animal Hospital of Ivy Square and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Animal Hospital of Ivy Square's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. We accept Visa, MC, Discovery, and Care Credit.
I have read this statement and -
I Agree
I Disagree

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