New Client Information-old-dominion-vets

New Client Information

Please fill out this form completely so we can provide you with the best possible service. Veterinary care cannot be provided without completion of this form. Completion of this form is not an appointment request. In addition to completing the form, please call (804) 876-0370 or email olddominionvets@gmail.com to schedule an appointment.

Name (First and Last)

Farm name

Phone Number

Farm address

Billing address

Client/Owner (not patient) date of birth

Brief description of your herd.

Authorization for Care

I verify I am the owner (or authorized agent for the owner) of the above-described herd. I authorize veterinary care, including emergency care, anesthesia, surgery, and euthanasia, as deemed necessary by the veterinarian. I accept the risk inherent in any anesthesia or surgery and release Old Dominion Veterinary Services (ODVS) of any liability associated with such procedures.

I agree to the Authorization for Care.

Financial Agreement

Payment is due at the time that service is rendered. There will be a finance charge of 2.5% per month for any unpaid balance. Accounts 60 days past due will be turned over to collections. An additional fee of up to 30% of the balance due will be added to total owed if turned over to collections.

I agree to the Financial Agreement.

I agree to allow Old Dominion Veterinary Services permission to use photographs and/or videos of me and my animals in print and digital publications and communications related to the work of ODVS.

Yes.

No.

Your Signature