Client Registration Form CLIENT INFORMATIONFirst & Last Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* May we use your pet’s photo and name in our marketing efforts and social media?* Yes No Do you authorize any other person(s) to make decisions regarding your pet’s care?* Yes No Name of authorized caregiver* First Last Authorized caregiver phone*How did you hear about our hospital?* Drive by Google search Advertisement Event Other Referred by Other* Referred by* Payment Policies - Dulles South Veterinary Center accepts all major credit cards (Visa, MasterCard, American Express, and Discover), CareCredit, Scratch Pay, cash, and checks. Should your check be returned for insufficient funds, you expressly authorize your account to be electronically debited or bank drafted for the check plus a $25 service charge and any other applicable fees assessed by your financial institution. The use of a check is your acknowledgment and acceptance of this policy and its terms and conditions. * By signing below, I agree that I am the owner or the responsible agent for the animal(s) registered to my account. I certify that I am over 18 years of age. I hereby authorize veterinarians and staff employed by the partners of Dulles South Veterinary Center (Aldie Veterinary Hospital, LLC and/or Dulles South Animal Emergency & Referral Hospital, LLC), hereinafter referred to as DSVC, to examine, prescribe, and treat the patients I register on my account. I assume responsibility for all charges incurred in the care of this/these animal(s). I also understand that all professional fees are due at the time services are rendered. Signature*PhoneThis field is for validation purposes and should be left unchanged. Δ
