Are you: new to the area? changing veterinary care providers? a first-time pet owner? adopting/purchasing a new pet? How did you learn of our clinic? (required) Community HOA Letter Client/Friend (please specify below) Drive by/Sign Stream Valley Mailer Business/Organization (please specify below) Online (please specify below) Other (please specify below) Specify
Name of Pet (required) Species (required) Dog Cat Other (please specify below) Specify Breed (required) Color (required) Birthdate (required) Sex (required) Male Male Neutered Female Female Spayed Reason for Visit New/Puppy/Kitten/Pet Exam Adult Preventive Care Exam Illness/Injury Any current medications? Current diet
Second Pet Information
Name of Second Pet Species Dog Cat Other (please specify below) Specify Breed Color Birthdate Sex Male Male Neutered Female Female Spayed Reason for Visit New/Puppy/Kitten/Pet Exam Adult Preventive Care Exam Illness/Injury Any current medications? Current diet
Please list any additional pets' information here
Previous Records: To expedite and enhance your pet(s)' care at the initial visit, we request that vaccine and any other vital medical history be provided to us as far in advance of your appointment as possible. Please let us know how we may expect to receive those records. My pet(s)' medical records will be (required) faxed to (703) 723-8509 emailed to firstname.lastname@example.org
Notice of Hours: In accordance with Virginia Law, we are required to inform you that Stream Valley Veterinary Hospital (SVVH) does not provide 24-hour medical care. Our office hours are as follows: Monday - Friday 7am - 7pm, Saturday 8am - 3pm, and Sunday 5pm - 7pm (for boarder pick up only). Our doctors are available to provide medical care generally Monday - Friday 8:30am - 6pm (with a 12pm - 2pm lunch break) and Saturday 8:30am - 2pm (with a 12pm - 1pm lunch break). Should your pet have an emergency outside of these hours, you may need to call or be referred to the Animal Emergency Hospital at The Life Centre in Leesburg at (703) 777-5755. Acknowledgement of Hours: (required) I understand E-Mail Address : Email and/or Text Permissions In providing the above email address and/or cell phone number, I give Stream Valley Veterinary Hospital permission to contact me via email and/or text to remind me of pet's appointments and vaccine/medical procedures, to share educational materials, and to alert me to certain events or issues within the practice.
|Note: Many email and text programs are "opt out" should you wish not to participate, and you may contact us with any specific concerns. Selection (required) a I agree (email) b I agree (text) c I do NOT agree Additional Responsible Parties: I, the above listed client, am the primary responsible party in terms of medical and financial decisions for the above pet(s). However, the following person(s) is/are authorized to make medical and/or financial decisions in my absence. It is my responsibility to notify Stream Valley Veterinary Hospital in the event of any related changes. (authorized to make decisions) Contact Number (authorized to make decisions) Contact Number Authorization of Responsibility: I understand, by indicating "I agree" and submitting this form, that I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of above animal(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. Please select: (required) I agree I disagree