New Client Registration Form

Step 1 of 3

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Date
Owner Name*
Address*
Street Address Address Line 2 City State ZIP Code
Email Address
Home Number
Work Number
Cell Number*
Co-Owner Name
Co-Owner Work Number
Co-Owner Cell Number
Name of Previous Veterinary Practice
Phone
Are you or your spouse Active Military?
- Yes
- No
How did you find out about our practice?
Current Pet Insurance Company?

First Pet
Select One:*
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Date of Vaccinations
Rabies DA2P Parvo Corona Bordatella
Date of Vaccinations
Rabies FELV ENT-FVRCP FIP
Second Pet
Select One:
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Date of Vaccinations
Rabies DA2P Parvo Corona Bordatella
Date of Vaccinations
Rabies FELV ENT-FVRCP FIP
Third Pet
Select One:
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Date of Vaccinations
Rabies DA2P Parvo Corona Bordatella
Date of Vaccinations
Rabies FELV ENT-FVRCP FIP

Please use the following box to give us any other relevant information about your pet(s):
Authorization
Please enter your initials below each policy acknowledging them. Thank you!
I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for the card of this animal. I also understand that payment is due at the time services are rendered and that a deposit may be required for surgical treatment.
Our practice offers an interest free payment plan through a 3d party provider. Additionally, we file insurance claims for Trupanion pet insurance clients. If the claim is approved, clients are responsible for their co-pay. The balance is paid directly to the hospital. If you would like a certificate for one month of free Trupanion pet insurance, please ask the Receptionist at check-in.
If an appointment is missed without at least 24 hours prior notice there will be a $25 missed appointment fee. This missed appointment fee is for all appointments including routine, drop off, technician, bath and grooming appointments.
If your pet is not picked up within 30 minutes past our closing time there is be a $25 late pickup fee assessed. Over 30 minutes past closed and you pet will be considered a boarder and boarding fees will be applied.
I authorize my pet's pictures to be utilized in materials to represent Loving Touch Animal Hospital including but not limited to our Facebook Page, Twitter, and Website.
Our hours of operation are Monday through Friday, 9am - 5pm and Saturday, 9am - 3pm. If you have an emergency, we will stay after hours to take of your pet. However, we urge you to contact us first thing in the morning in the event of an emergency.
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 3

First Pet

Second Pet

Third Pet

Authorization

OUR HOURS

Our Address

Quick Links

AFTER HOURS EMERGENCIES

Veterinary Referral Center of Northern Virginia