Client Forms & Clinic Policies

Clinic Policies

New Client Request Form

Pet Owner Information

* Indicates required field

How did you hear about us? *

Internet search A friend or family member Another Vet Hospital Other

Who can we thank for referring you? *

Name *

First

Last

Primary Phone Number *

Email *

Spouse/Partner or Relative's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Secondary Phone Number *

How many pets do you have? *

Previous Veterinary Clinic, if any *

Patient Information

Your Pet's Name *

Pet's Date of Birth *

Species *

Sex *

Has your pet been spayed or neutered? *

Breed (if unknown put unknown or mix breed) *

Color/Markings *

Microchip # (if applicable) *

Vaccine History/Dates? *

Does your pet have any known health conditions or issues? Surgeries? *

Is your pet on any medications? *

Describe the reason for your pet's visit *

Patient #2 Information
If you have more than two pets pets we will collect additional patient information from you at or before your pet's first visit

Pet's Name *

Pet's Date of Birth *

Species *

Sex *

Is your pet spayed or neutered? *

Pet's Breed (if unknown, put unknown or mixed breed) *

Color/Markings *

Microchip number (If applicable) *

Vaccine History/Dates? *

Does your pet have any known health conditions/concerns? Surgeries? *

Is your pet on any medications? *

Describe the reason for this pet's visit *

Notes/Comments *

YOUR DIGITAL SIGNATURE BELOW ACKNOWLEDGES THAT YOU HAVE READ AND AGREE TO ALL TERMS

Please Acknowledge *

I have read and agree to adhere to clinic policies I understand the appointment & prescription policy I understand my payment options

Upon request estimates are gladly provided via email prior to your pet's appointments. All fee's must be paid in full at time of service.

All of our patients are superstars! We would love to have your permission to take their picture for our medical records, social media pages and website. No personal information is ever shared. Do you give us permission to take photo(s) of your pet(s)?

Photo Release *

I DO consent I do NOT consent

Digital Signature *

Please email us your pet's medical records at vet.churchville@gmail.com

Many Veterinary practices across the United States and beyond are facing the challenge of having limited licensed Veterinary Professionals while also being inundated with a stream of cases both urgent and non-urgent. Churchville Veterinary Hospital P.C. is taking remarkable efforts behind the scenes to balance these high demands for Veterinary care with our day-to-day capabilities.

We are currently experiencing high volumes of clients looking to transfer care to us. New client appointments maybe limited.
Thank you for choosing Churchville Veterinary Hospital P.C. If you have any questions, please don't hesitate to give us a call.

Submit

Dental Options Form

Please fill out this form prior to your pet's scheduled procedure/surgery. You can either e-mail it to us prior or bring it with you.

CPR Consent Form

Please fill out this form prior to your pet's scheduled procedure/surgery. You can either e-mail it to us prior or bring it with you.

Reptile & Amphibian History Form

Please fill out this form prior to your first scheduled appointment. You can either e-mail it to us prior to your appointment or bring it with you.

Small Mammal History Form

Please fill out this form prior to your first scheduled appointment. You can either e-mail it to us prior to your appointment or bring it with you.

Forms & Policies

Clinic Policies

New Client Request Form

Pet Owner Information

Patient Information

Patient #2 Information
If you have more than two pets pets we will collect additional patient information from you at or before your pet's first visit

Dental Options Form

CPR Consent Form

Reptile & Amphibian History Form

Small Mammal History Form

Office Hours

Get in Touch With Us

Helpful Info

Forms & Policies

Clinic Policies

New Client Request Form

Pet Owner Information

Patient Information

Patient #2 InformationIf you have more than two pets pets we will collect additional patient information from you at or before your pet's first visit

Dental Options Form

CPR Consent Form

Reptile & Amphibian History Form

Small Mammal History Form

Office Hours

Get in Touch With Us

Helpful Info

Patient #2 Information
If you have more than two pets pets we will collect additional patient information from you at or before your pet's first visit