New Client Registration - Animal Medical Centers of Loudoun

Welcome to Our Practice

Thank you for selecting us as your veterinarian! We are glad to have you here. To enable us to better serve you we ask that you please fill out the attached paperwork and provide us with all previous medical records for your pet.

We will do our best to honor our appointment schedule. Please note that time is a limited commodity; once lost, it cannot be regained. Our business runs by appointments, which assures each client and patient receive our full attention during the allotted time. Please be aware that if you arrive late for your appointment we may need to reschedule or require you to wait until the next available appointment. We will go out of our way to be fair and accommodate you in these situations; however, this is done as a courtesy to other clients and to keep appointments running on time.

Which Location Will Your Pet Be Seen At?

Ashburn Farms Brambleton

Client Information

Owner's Full Name

Co-Owner's Full Name

Address

Address Line 2

City

State

ZIP / Postal Code

Employer

Position

WE SEND ALL SERVICE AND APPOINTMENT REMINDERS VIA TEXT AND EMAIL

Best number to reach you

Best number to text

Best Email for Reminders

Additional Contact Information

Home Phone

Work Phone

Cell Phone

Co-Owner Contact Information

Home Phone

Work Phone

Cell Phone

Pet Information

Pet's Name

Date of Birth

Species

Breed

Color and Markings

Sex

Male Female

Spayed/Neutered

Yes No

Add another pet?

Second Pet's Name

Date of Birth

Species

Breed

Color and Markings

Sex

Male Female

Spayed/Neutered

Yes No

My pet(s) were last seen at (clinic)

Clinic Phone Number

Payment Policy

Payment is expected at the time services are provided.

A deposit may be required for extensive medical or surgical procedures. The hospital accepts VISA, MasterCard, Discover, American Express, Checks, and Cash. I understand that I will be responsible not only for the balance due, but any collection agency fees, court costs, and/or attorney fees that are incurred in the attempt to collect this debt. Please be advised that the hospital is not staffed during non-business hours. This applies to all office visits.

By checking below I agree that I am at least 18 years of age and assume full financial responsibility for the above-mentioned pets.

I agree to payment policy

Authorize Animal Medical Centers of Loudoun to use pictures or electronic media images of my pet(s) for any marketing purposes such as social media, website, etc. I understand that I may revoke this authorization at any time by notifying Animal Medical Centers of Loudoun in writing.

By checking below I agree that I am at least 18 years of age.

I agree to photo policy

How did you hear about our practice?

We like to thank our loyal customers for referrals and track our marketing efforts. Please take a moment to tell us how you found our practice.

THIS STATEMENT IS REQUIRED BY VIRGINIA STATE LAW

Please be advised that the clinic does not have continuous staff during non-business hours and major holidays. We do not offer overnight hospitalization for sick or injured animals. If your pet requires overnight care or hospitalization, please contact the animal emergency facility of your choice.

I understand the hours of operation and that the Animal Medical Centers of Loudoun do not offer overnight accommodations

Signature

Ashburn, VA

Brambleton, VA

Ashburn, VA

Brambleton, VA

Days :

Hours :

Minutes :

Seconds

Save $50 on Your Pet’s Next Visit

Summer is almost here! Save $50 on your pet’s next visit now through May 31. Offer valid for appointments scheduled and completed by May 31, 2026.

Use code 50FL

Must mention code 50FL at scheduling.
Cannot be combined with other offers or promotions.

New Client Form

Welcome to Our Practice

Client Information

Additional Contact Information

Co-Owner Contact Information

Pet Information

Add another pet?

Payment Policy

Ashburn, VA

Brambleton, VA

Ashburn, VA

Brambleton, VA

Save $50 on Your Pet’s Next Visit