Pre Appointment Form Call Virginia Beach Please enable JavaScript in your browser to complete this form. - Step 1 of 3Owner Name *FirstLastCo-Owner NameFirstLastPrimary Care Veterinarian:Hospital:Have any of your pets been seen by Dr. Paul Berdoulay? *YesNoEmail *Primary Phone *Secondary PhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePet’s Name *Species *DogCatSex *MaleNeutered MaleFemaleSpayed FemaleBreed *Color *Birth Date / Age *Your Pet’s Health Concern: *Method(s) of Payment: *CashCheckCredit CardCare CreditInsurance Provider (if applicable):I agree and understand that payment is expected in full at the time services are rendered. Should this account default and is referred to an attorney for collection, then I agree to pay all collection costs, including attorney fees, up to 40% of the principal amount due and owing when turned over for collection. I agree to pay interest on the unpaid balance at the rate of 1.5% per month (18% annum) from the date that monies become due and payable. *I have read and agreeWelcome and thank you for choosing us to collaborate on the care of your pet.NextThank you for taking the time to fill out this form. Your responses will help us to better care for your pet. We have found that using a pre-exam history form reduces the chances that one of your concerns will be missed during your visit.What is the primary reason you are having your pet examined today? Please list symptoms and when you first notice these symptoms. *What medication(s) or supplement(s) are your pet currently taking? List dose, instructions. (Please also bring medication(s) to your appointment.) *Have any of these medications helped the problem? *What do you currently feed your pet? Include all treats or any diet change within the past 2 months. *How much do you feed per day? *Do you have any other pets in the house? *Are they having these or any other symptoms? *What heartworm/parasite (flea/tick) control do you use for your pet? *Has your pet been outside of the state in the past 6 months? *When were your pets last vaccines? *Please list a HUMAN pharmacy that you use for medications:Pharmacy Name *Pharmacy Phone *Does your cat go outside? *YesNoHas your cat been tested for FeLV or FIV? *YesNoIf so, when? *NextCOMMONWEALTH OF VIRGINIA VETERINARY DISCLOSURE FORM(Please read carefully before signing)Affordable Veterinary Ultrasound, Endoscopy, and Internal Medicine business hours are as follows: Monday 8:00am to 4:00pm Tuesday 8:00am to 4:00pm Wednesday 8:00am to 4:00pm Thursday and Friday 8:00am to 4:00pm OR Alternating Thursdays and Opposite Fridays – Closed Saturday and Sunday - Closed The purpose of this form is to inform you that AVUE has no in-house, on-duty continuous medical staff care: Overnight, from closing time each weekday until opening time the next day. Weekends, from closing time on Thursday/Friday to opening time Monday morning at 8:00 am. The above weekend statement applies to the following holidays that we are closed: New Year's Day Memorial Day July 4th Labor Day Thanksgiving Day Christmas Day I have read this form and I understand and am aware of the above stated staffing hours of AVUE. *I have read and understandThis disclosure form is a requirement by the Commonwealth of Virginia Department of Health Professions. This form must be signed before we can see your pet for services. Please feel free to ask any questions if you do not understand this policy.Print Name *FirstLastSignature * Clear Signature Date *Submit