65 Jefferson Court
Gordonsville, VA 29942
(540) 832-1751
New Client Information
1. Name (First, Last):______
2. Street Address: ______
3. Mailing Address (if different from above):______
4. City: ______ZIP:______County:______
5. Home Phone:______Work Phone:______Cell Phone: ______
6. Primary Contact Number (Include area code): ______
7. Employer:______Driver’s Lic # ______
8. Email address:______
We send emails to remind you if your pet(s) are due for vaccines
and register you to use our online pharmacy
9. Spouse’s Name: ______Spouse’s Phone Number: ______
10. Referred By: ______The client who referred you will receive a $10.00 credit.
Please note, we do not accept checks as a form of payment.
Pet Information
1.Pet’s Name: ______
Please circle your answers: Canine/Feline Male/Female Spayed or Neutered: Yes/No
Breed: ______Color: ______DOB/Estimated Age: ______
2.Pet’s Name: ______
Please circle your answers: Canine/Feline Male/Female Spayed or Neutered: Yes/No
Breed: ______Color: ______DOB/Estimated Age: ______
3.Pet’s Name: ______
Please circle your answers: Canine/Feline Male/Female Spayed or Neutered: Yes/No
Breed: ______Color: ______DOB/Estimated Age: ______
Name of previous Animal Hospital (Veterinarian):______
By signing this form, I understand that I am responsible for this account and any charges incurred. I am also aware that Crossroads Animal Hospital requires 24 hour notice before canceling an appointment. If 24 hours notice is not received or the appointment is missed altogether without cancellation notice, there may be a $40.00 missed appointment charge applied to your account per each exam that was missed.
Client Signature:______Date:______
Name Printed:______
Disclosure of Hours
In accordance with state law, we are required to provide you with a disclosure of our business hours. During the times listed below, our facility is open and fully staffed. When the hospital is closed, there are no employees or caretakers on the premises. Any animals remaining at the clinic after the hours listed below will be unattended.
MONDAY - FRIDAY: 7:30AM - 7PM
SATURDAY: 8AM - 2PM
Sunday – Closed
Client Signature: ______Date: ______