Harmony Animal Hospital remains open. Due to COVID-19, we are taking all precautions to ensure the safety of our clients and staff while continuing to provide the best possible care for our patients. We are asking clients to call upon arrival so that we may assist you curbside. If you choose to come inside the clinic, we require you wear a mask and are allowing up to two clients to accompany the patient. 703.643.9797

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Fear Free Certified Clinic |

(703) 643-9797 | 6940 S Kings Hwy #208, Alexandria, VA 22310

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New Client Patient Form

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Pet Parent #1: Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pet Parent #2: Name
First Last
Relationship
Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pet Parent #1 Cell*
Pet Parent #2 Cell
Home Phone
Work/Other Phone
Please check the PRIMARY phone*
- Pet Parent #1 Cell
- Pet Parent #2 Cell
- Home Phone
- Work/Other Phone
PRIMARY Email for the Account*
Secondary Email
How did you hear about us?*
What animal hospital were you and your pet visiting previously?*
Is your pet enrolled in an insurance plan?*
- Yes
- No
If yes, which Insurance company?
I approve TEXT reminders:*
- Yes
- No
approve EMAIL reminders:*
- Yes
- No
I approve Harmony Animal Hospital’s use of my pet’s images for social media purposes:*
- Yes
- No
I consent to enrollment in Harmony Animal Hospital’s online pharmacy (no obligation):*
- Yes
- No
I understand that there will be a $25 fee for an appointment no-show, and $50 for a surgery no-show. I understand that all fees are due at the time services are rendered. (Client Signature)*
Date*
Date Format: MM slash DD slash YYYY

First Pet
Pet #1: Name*
Date of Birth*
Breed*
Sex*
*
- Spayed
- Neutered
- NOT Spayed / Neutered
What is your pet currently eating?*
Does your pet have any known allergies?
What Heartworm prevention is your pet currently taking?
What Flea and Tick prevention is your pet currently taking?
Is your pet currently on any medications?
Does your pet have any known health issues?
What Health Insurance does your pet have (if any)?
Second Pet
Pet #2: Name
Date of Birth
Breed
Sex
- Spayed
- Neutered
- NOT Spayed / Neutered
What is your pet currently eating?
Does your pet have any known allergies?
What Heartworm prevention is your pet currently taking?
What Flea and Tick prevention is your pet currently taking?
Is your pet currently on any medications?
Does your pet have any known health issues?
What Health Insurance does your pet have (if any)?
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Email
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Harmony Animal Hospital

Phone: (703) 643-9797 Address: 6940 S Kings Hwy #208, Alexandria, VA 22310

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