New Client Form

Name: Church Hill Animal Hospital
Address: 322 N 25th St, Richmond, VA, 23223, United States
Telephone: 804-644-8200
Price range: $

Please contact us for an appointment prior to completing the New Client Information form to determine if we are accepting new clients.

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Thank you for choosing Church Hill Animal Hospital!

Please contact us for an appointment prior to completing the New Client Information form to determine if we are accepting new clients at this time. Thank you!

We look forward to providing care for your animal companion. Please help us get to know you and your companion by completing the following information before your first appointment. If you need immediate assistance, please call us directly at 804-644-8200.
Please note: All fields marked with a * are required.

Date *

Please choose one

Mr.
Mrs.
Ms.
Dr.

Owner's Name *

First

Last

Spouse/Other/Partner's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Spouse/Other/Partner's Phone

Email *

Employer's Name

First

Last

Spouse/Other/Partner's Employer Name

First

Last

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

We will gladly prepare a written estimate if requested. We accept Master Card, Visa, cash and checks with ID. Returned checks will acquire a $35.00 processing fee. In the event this account is turned over for collection, the owner/agent is responsible for fees in the amount of 33 1/3% of the outstanding balance.

Signature of client responsible for pet(s). *

Date *

How did you hear about us? (please check all that apply)

Phone book
Location
Referral
Hospital Sign
Advertisement
Other
Individual

Animal Medical History

Please complete all information for each animal.

Name *

Species (cat, dog, etc.) *

Breed *

Color *

For non-pedigreed cats please check one:

Short hair
Medium hair
Long hair

Age *

Date of Birth

Sex *

Male
Neutered Male
Female
Spayed Female

Is your pet on any medication?

If yes, please list ALL medications your pet is currently taking, including heartworm preventative and flea medications.

Are you bringing in a second pet? *

Pet 2

Name *

Species (cat, dog, etc.) *

Breed *

Color *

For non-pedigreed cats please check one:

Short hair
Medium hair
Long hair

Age *

Date of Birth

Sex *

Male
Neutered Male
Female
Spayed Female

Is your pet on any medication?

If yes, please list ALL medications your pet is currently taking, including heartworm preventative and flea medications.

Are you bringing in a third pet? *

Pet 3

Name *

Species (cat, dog, etc.) *

Breed *

Color *

For non-pedigreed cats please check one:

Short hair
Medium hair
Long hair

Age *

Date of Birth

Sex *

Male
Female
Neutered Male
Spayed Female

Is your pet on any medication?

If yes, please list ALL medications your pet is currently taking, including heartworm preventative and flea medications.

Are you bringing in a fourth pet? *

Pet 4

Name *

Species (cat, dog, etc.) *

Breed *

Color *

For non-pedigreed cats please check one:

Short hair
Medium hair
Long hair

Age *

Date of Birth

Sex *

Male
Female
Neutered Male
Spayed Female

Is your pet on any medication?

If yes, please list ALL medications your pet is currently taking, including heartworm preventative and flea medications.

Contact Us

Are you a new client? Please click here!

Name *

First

Last

Email *

Phone

How can we help you? *

Committed to Your Pet’s Health & Happiness

Veterinary Care in Richmond, VA



322 N 25th St Richmond, VA 23223



804-644-8200

804-644-8900



info@churchhillanimalhospital.com

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Appointment Hours

Monday – Friday: 9:00 AM – 12:00 PM & 2:00 PM – 5:00 PM

*Please call ahead for appointments or use our online form to request one.

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Office Hours

Monday – Friday: 7:30 AM – 5:00 PM
Surgical Drop-Offs: 7:45 AM - 8:30 AM

Welcome to Church Hill Animal Hospital!

Please call us directly at 804-644-8200 to determine if we are accepting new clients at this time.