Rose Hill Veterinary Practice, PC – Small Animal
Small Animal Medicine and Surgery
21 Christmas Tree Lane
PO Box 248
Washington, VA 22747
(540) 987-9300
Kimberly S. Cole, DVM
Betty L. Myers, DVM
Pamela A. Thayer, DVM
Client Information:
Name(s):
Mailing Address:
Physical Address:
Home Phone:
E-mail address:
Work Phone:
Employer’s Name and Address:
Driver’s License Number:
Patient Information:
Pet’s Name:
Canine/Feline/Avian/Pocket Pet/Reptile
Male/Female
Color
Tattoo and/or Microchip #:
Registration#:
Breed:
Neutered? Y/N
Age or DOB:
Registering Organization:
Prior medical conditions or surgeries – please list condition and dates
By signing below, I hereby acknowledge that payment is due at the time services are rendered. I accept
responsibility for any charges incurred in providing veterinary care to patients/pets listed under my name and
understand that in the event of non-payment, it is understood that I, the undersigned, will be responsible for any
and all expenses associated with collection efforts, including late fees, attorney fees, and court costs. A Finance
Charge of 1.5% monthly (18% APR) will be added to all balances 30 days and older. I may request an estimate
before services are rendered.
Privacy Policy: RHVP, PC-SA is committed to protecting your privacy. RHVP, PC-SA does not sell, rent, or give out any personal, or patient information without your
permission. RHVPPC-SA makes every attempt to keep your information secure.
Signature
Date
Signature
Date