OWNER’S INFORMATION

Pronouns

Name *

First

Last

Full Names of all persons with Medical/Financial/Legal Authority regarding your cats:

Relation

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone *

Email *

Date of Birth

Occupation

Employer/Business Name

PATIENT’S INFORMATION

Pet Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Pet’s Birth Date

Breed

Color

Current Medications

Allergies/Reactions to Medications/Foods

Medical Problems

Does Cat Ever Go Outdoors?

Yes
No

Diet (Please include brand names and indicate canned, dry, or semi-moist):

REFERRAL INFORMATION

Has another hospital treated this cat?

Yes
No

If yes, when

Where?

How did you become aware of our hospital?

MEDICAL INFORMATION

I give consent to release my cats medical records to a Referral Specialist, Referral Center, or Emergency Hospital when Specialty Medical Care is indicated. I also give permission for the Cat Hospital of Fairfax doctors to consult with Specialists at Referral Centers or Veterinary Schools for patient care when in the best interest of the patient.

I have read and understand the above statements

Relation Hospital names

Signature of Owner/Agent *

Clear Signature

Date *

PHOTO CONSENT

I give The Cat Hospital of Fairfax permission to take photographs of my cats and share them on Social Media platforms.

Yes
No

Initials of owner/agent:

Disclosure of Hours

The Cat Hospital of Fairfax is staffed from 8:00am to 5:00pm Monday through Friday.
The Cat Hospital of Fairfax is not staffed from 5:00pm Friday through 8:00am Monday.
The Cat Hospital of Fairfax is not staffed on observed Holidays.
Doctors’ hours are by appointment only.
Doctors and/or staff will make Clinic rounds twice daily or as the medical treatment requires for any hospitalized patients.

Financial Policy

Thank you for choosing The Cat Hospital of Fairfax. Our primary mission is to deliver the best and most comprehensive veterinary care for your cats. Our fees are based on the quality of service we provide, expertise of our staff, our facilities and equipment, and continuing education.

We encourage you to discuss fees with us for any veterinary service your cat may need. The Cat Hospital of Fairfax requires payment in full at the end of your cat’s examination and/or at the time of discharge. We accept debit cards, pre-paid cards, CareCredit, VISA, Mastercard, Discover (a 3% surcharge will be applied to all credit card transactions).

For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

Telecommunication Fee Policy

In cases where email or telephone consultations are appropriate, a veterinary consultation fee may be charged. When assessing a patient with ongoing healthcare needs, to address client concerns, a complete review of medical records is required. This also applies to prescription refills/renewals that require a review of the case or change of medical management. The professional fees will include time for review and case management as well as time with telecommunication.

Telecommunications within a timely manner directly after an examination regarding medical, laboratory, or case management information are not charged a fee; these are included in the health examination visit.

I have read and understand the above statements regarding the Disclosure of Hours, Financial Policy, and Telecommunication Fee Policy:

Signature of Owner/Agent *

Clear Signature

Date *

Online Forms

New Client Form

New Client Form

OWNER’S INFORMATION

PATIENT’S INFORMATION

REFERRAL INFORMATION

MEDICAL INFORMATION

PHOTO CONSENT

Disclosure of Hours

Financial Policy

Telecommunication Fee Policy

We’re Here to Help

Address

Contact Information

Hours of Operation