New Client Registration Form

Owner's Name

Name*

First Last

Co-owner's Name & Contact #

Name

First Last

Phone

Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day-Time Phone*

Evening Phone

Mobile Phone

SMS Consent

I agree to the below policy.

Effective Date: February 10, 2025
By opting in to receive SMS messages from Market Street Animal Clinic (“we,” “us,” “our”), you agree to the following terms:
1. SMS Messaging Service
By providing my phone number, I consent to receiving SMS text messages from Market Street Animal Clinic for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out.
2. Message Frequency
You will receive up to 4 messages per month.
3. Message and Data Rates
Message and data rates may apply based on your mobile carrier’s terms.
4. Privacy Policy
Your information will be handled in accordance with our Privacy Policy, which can be viewed at https://marketstreetanimalclinic.com/privacy
5. Opt-Out Instructions
You can opt out at any time by replying “STOP” to any SMS message. Reply HELP for support. You may also contact us directly at Market Street Animal Clinic, 210 East Market St., Leesburg, VA, 20176. (703) 777-6661
6. Liability
We are not responsible for any charges, errors, or delays in SMS delivery caused by your carrier or third-party service providers.
By opting in, you confirm that you are the owner or authorized user of the phone number provided and that you are at least 18 years old.

Email*

Enter Email Confirm Email

How did you find out about our practice?

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

What food does your pet eat?

does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Owner's Name

Co-owner's Name & Contact #

Address

Pet Information

Contact

Location

Hours