(757) 473-0111

New Client/New Patient Form

Required Fields are Marked [*]

Owner’ Name:*
First Last
Email*
Primary Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Driver's License #*
Employer*
Phone
Spouse / Additional Owner Name:
Spouse / Additional Owner Phone:
Spouse / Additional Owner Driver's License
Pet Information
Pet Name*
Species*
- Dog
- Cat
- Bird
- Reptile
- Rabbit
- Ferret
- Small Mammal
- Other
What Species?*
Gender*
- Male
- Female
- Unkown
Altered?*
- Yes
- No
Date of Birth*
Breed
Color / Markings*
Normal Diet:*
Allergies:*
Current Medication (s):*
Previous health problems:*
Please call the veterinarian office you were using and request that they send your pet's records to us.

Email: petcare@petcarevb.com
Fax: 757-499-6166
Upload your pet's records. (jpg and pdf format only)
Drop files here or

Accepted file types: jpg, pdf, Max. file size: 60 MB.
Do you have any other pets in your home?*
- Yes
- No
If "Yes" above, what kind?
Have you or any of your pets been out of the area lately?*
- Yes
- No
If "Yes" above, where?
Tell us how you found Pet Care
How did you find us?*
- Referral
- Our Location
- Local Event
- Friend
- Veterinarian
- Online
- Website
Who may we thank?*
How did you find us online?*
- Facebook
- Google
- Yahoo
- Bing
- Yelp
- Rescue Group
Professional fees are to be paid at the time services are rendered*
- I Agree
Date
MM slash DD slash YYYY
Entering your name will serve as a digital signature:*
First Last
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5201 Virginia Beach Blvd.,
Virginia Beach, VA 23462
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