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Hours 6401 Shiplett Blvd
Burke, VA 22015

New Client Form

Co-Owner Name (first & last):*

Co-Owner Title:*

Co-Owner Phone Number:*

Would you like your confirmations by text message/email?*

Yes

No

How did you hear about us?*

If you were referred by a friend; can you please tell us their name so we can thank them:*

Patient 1 Information:

Pet's Name*

Species*

Breed*

Age / DOB*

Sex*

Color/Markings*

Please provide dates/information for the following:

Distemper Vaccine:*

Rabies Vaccine:*

Bordetella Vaccine*

Other Vaccine:*

Heartworm Test:*

Microchip #:*

Patient 2 Information:

Pet's Name*

Species*

Breed*

Age/DOB*

Sex*

Color/Markings*

Please provide dates/information for the following:

Distemper Vaccine:*

Rabies Vaccine:*

Bordetella Vaccine:*

Other Vaccine:*

Heartworm Test:*

Microchip #:*

General Information

Previous Veterinarian and Phone Number:*

I understand that my pet’s picture may be used on social media sites.*

Financial Policy

Thank you for choosing Burke Veterinary Clinic. Our Primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Burke Veterinary Clinic requires payment in full at the end of your pet’s visit.

Payment Options:

You can choose from:

Cash, Check, Debit Card, Visa®, Mastercard®, American Express®, Apple Pay®, and Discover®

We also offer an in-house payment option for well-established clients and with the approval of management. Your bill can be paid in installments over 3 months with no interest. One-half of the bill must be paid at the time of initial service, with the remaining balance paid in two more monthly payments. At the time of service, we require a valid credit card number for payment of the balance.

If you have an account 60 days past due, with no payment plan in place, Burke Veterinary Clinic may relinquish your balance owed to a collection agency. We make every effort to prevent this from happening. If we have to relinquish your account, the collection agency charges 30% of the balance owed.

Additional Policy Information:

Burke Veterinary Clinic charges $30.00 for returned checks. A fee of $25.00 may be charged for clients who miss more than 3 appointments in a calendar year without notice.

For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By entering your name below, your typed name will represent your signature and indicate that you agree to the foregoing terms of payment:*

We require all new clients to pay a non-refundable deposit to reserve an appointment. Please select "yes" below to indicate that you understand this policy.*

Yes

DISCLOSURE:

The Common Wealth of Virginia requires us to provide this disclosure to all clients. Our business hours are listed below:

Monday through Friday 7:30 am to 6:30 pm

Saturday 8:00 am to 3:00 pm

Staff are NOT in continuous attendance from 6:30 pm to 7:30 am Monday through Friday and from 3:00 pm Saturday to 7:30 am Monday. We do not offer after-hour care.

By entering your name below, your typed name will represent your signature and indicate that you have read and understand the aforementioned information.*

Today's Date:*

Burke Veterinary Clinic