New Client Form (Online) Step 1 of 616%Owner Name*Co-Owner NameAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPhoneMilitary Yes No Senior Yes No Recommended by Whom?Place of Employment First PetSelect One:* Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Second PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Third PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.Type Signature I, the undersigned, authorize the veterinarians and staff of NoVa Mobile Vet, PLLC to examine the animal(s) described herein. I also authorize any medical treatment or diagnostic tests approved by me and deemed necessary based on findings during the initial examination.Furthermore, I authorize NoVa Mobile Vet, PLLC to obtain medical information pertaining to my pet(s) from other veterinarians, and to release my pet(s) medical information to other veterinarians, as needed to facilitate the care of my pet(s).I assume financial responsibility for all charges, including all fees associated with collections such as court costs, administrative fees and attorney's fees. All services must be paid in full during your pet’s visit. All account balances 60 days or older will be sent to collections and all discounts or coupons will be removed from your account and an additional charge of $100.00 will be added to your total amount due at that time.I hereby certify that all information given on this form is truthful and accurate to the best of my knowledge and I am solely responsible for any inaccurate information given, including, but not limited to, medications taken or food ingested by the animal.SignaturePrint NameDate MM slash DD slash YYYY At NoVa Mobile Vet, our goal is to provide high quality veterinary care. We have implemented an appointment/cancellation policy which enables us to better utilize appointments for our patients in need of veterinary care. As we have a limited number of appointments we can see daily, we require 24 hours notice of cancellation. If you cannot make your appointment, please let us know as soon as possible so we can offer it to someone else. Your consideration is appreciated as the sooner you call us, the greater our chances of reallocating the appointment slot to someone else.*If a person fails to provide 24 hours notice prior to cancelling a scheduled wellness appointment, he/she will incur a $100 fee for the late notice.*If a person fails to provide 24 hours notice of cancellation for a scheduled surgical, dental, or anesthetic procedure, he/she will incur a $200 fee for the late notice.We will accept cancellation calls to our main number at 1-866-946-7387 or cancellation emails to firstname.lastname@example.org.****This policy applies to new and existing clients who fail to provide 24 hours notice of cancellation.****Acknowledgment:I, the undersigned, agree to the terms and conditions of this cancellation policy.SignaturePrint NameDate MM slash DD slash YYYY Per Article 54.1--3806.1 of Virginia code, please review the following information: The NoVa Mobile Vet office is not staffed continuously; the office operates from 9 am. to 3 6pm. Monday through Friday, and Saturday 9 am.- to 6 pm. Appointments are seen from 12pm -to about 6 pm Monday through Friday, and Saturday 12pm to 4pm. Phone calls received outside of normal business hours will be returned on the next business day. In the event of an after hours emergency, please contact your nearest emergency veterinary hospital. I hereby certify that all information given on this form is truthful and accurate to the best of my knowledge and I am solely responsible for any inaccurate information given, including, but not limited to, medications taken or food ingested by the animal(s).SignaturePrint NameDate MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.