New Patient Form | Animal Eye Care of Richmond

Note: Please complete the form below completely and accurately so that we can get to know you and your pet(s) before your visit. If this is an emergency or your pet requires immediate attention, please call us at (804) 355-5594 for a faster response.

Pet Name

Pet Name *

Owner Information

First Name *

Last Name *

Email *

Phone *

For appointment reminders, do you prefer your reminder via email or text message?

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Place of Employment

Secondary Contact Name

Secondary Contact Phone

Pet Details

Primary or Referring Veterinarian *

Species *

If other, please specify species.

Breed

Color

Age

Sex

Medical Information

Important Information

Please read the following information regarding our services and policies and sign to state you understand and agree to these terms.

Payment is due at the time of service. We do not bill for services or medications.
All appointments (including new, follow-ups, and post-operative) will have an exam fee.
Payments can be made by cash, check, Care Credit, and any major credit card.
We charge a 3% surcharge for all credit cards. This does not apply to debit cards.
There is a $40.00 fee for all returned checks. Any delinquent account requiring legal action may be subject to a 33 1/3% attorney's fee in addition to all court costs.
Animal Eye Care of Richmond is NOT a boarding facility, therefore all pets left for procedures/surgeries must be picked up by the close of business the day of the procedure.
If your pet is not picked up by the close of business, we will transport your pet to the Veterinary Referral and Critical Care Center in Manakin Sabot, and you will incur a travel charge from us AND additional boarding fees, etc. from the emergency center.

Signature *

Please sign above to continue

Date *