Thank you for giving Chester Animal Clinic the opportunity to care for your pet(s). To ensure the best care possible, please fill out this form completely. We’ll reach out with any questions.

If you or anyone in your household (including your pet) has been exposed to COVID-19 or tested positive for COVID-19 in the last two weeks, we ask that you schedule your appointment ten days after you are symptom- and fever-free. Thank you for your consideration.

Client's Name *

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**Your email address is strictly used for internal purposes and for communication directly with you. We send out revised policies, inclement weather updates, estimates for boarding/medical services as well as surveys on how to improve our services.

Address *

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Cell Phone *

We ask that your primary phone # be a cell phone number as we will text reservation confirmations, policies, reminders, etc via text.

Emergency/Alternate Phone

Spouse/Partner

Spouse/Partner Phone

Please list all pets that should be active on your account. Only list pets that currently live in your household. Please include each pet's name, species, breed, sex, if they are fixed, color, and age.

Your pets' picture or video may be taken while they are with us and used for Chester Animal Clinic’s advertisement (www.lyenanimalhospitals.com) or other social media purposes (FaceBook, SnapChat, Instagram, etc). Please indicate if you authorize for their pictures/videos to be posted or used.

I approve for Chester Animal Clinic to post and use all pictures/videos taken of my pet.
I do NOT authorize for Chester Animal Clinic to post or use any pictures/videos taken of my pet.

If you do not authorize for your pet’s picture to be included in our marketing materials/venues we may still use a picture of your pet in our patient records for our internal identification only.

PAYMENT: Payment in full is required at the end of your visit today. We accept Cash, Visa, Mastercard, American Express Personal Checks, CareCredit and Scratchpay for payment. Should you opt for CareCredit or Scratchpay as your form of payment, we ask that you apply prior to your visit to streamline your appointment. We do not accept American Express or Discover. Please note that when clients provide us checks as a form of payment we will run their check through a funds verification system. When you provide a check as payment, you authorize us to either use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use the information from your check to make an electronic funds transfer, funds may be withdrawn from your account as soon as the same day you make your payment. A returned check fee of $35.00 will be electronically debited from your account in the event your electronic transfer is returned from your financial institution. *

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TRANSFER OF OWNERSHIP: If you have a change in family status or pet ownership we require the proper documentation to transfer your pet's records. In the State of Virginia your pet(s) medical records are property of Chester Animal Clinic and we are responsible to ensure only those owners who have lawful ownership of your pet may have access to their records and to make medical decisions for that pet. If you have relinquished your pet to another owner, you will need to complete a Transfer of Ownership form for Chester Animal Clinic to legally recognize the new owner. If you have a change in marital status and the spouse who has the pet is not listed on the account we cannot transfer their records or recognize that individual for making life decisions for that pet. We understand that may seem inconvenient however we are looking out for your pet's best interest and care. We are able to email or fax that document to you directly to make this process as seamless as possible. *

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APPOINTMENTS: To ensure your appointment is as timely as possible, we strongly recommend that the pet parent (responsible party) attend the exam with the Veterinarian. Additional fees ($60 or more) will apply to your pet's exam should you send an individual with your pet that is not familiar with your pet's medical condition/symptoms and is not financially responsible, OR you are not able to discuss with the doctor your pet's treatment and request a time other than the scheduled appointment for your pet. We offer appointments 6 days a week, including 8 am - 5 pm on Saturdays - please take advantage of our extended hours to make sure you are present for your pet's exam. *

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APPOINTMENT CANCELLATION/NO SHOW POLICY FOR APPOINTMENTS: When appointments are not kept or canceled in a timely fashion, it prevents us from scheduling patients that need medical attention. All new clients will be required to place a deposit equal to the exam fee to secure their pet's appointment. The deposit will be applied towards your pet's exam fees at the time of discharge. If you're unable to cancel the appointment with a 24-hour notice, the deposit will be forfeited. *

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VACCINE NOTIFICATION & DISCLOSURE: Vaccines are administered to your pet to produce antibodies (to build up their immunity) against certain diseases. These vaccines are an important part of your pet’s well-being and protection. Most pets that die during their puppy/kitten stage die from not being properly vaccinated. It is critical during their first few months to get this done as quickly and consistently as possible. Puppies & kittens do require vaccines to be boosted every 3-4 weeks during their first few months. Our staff will be providing you with our recommended vaccines, tests and preventatives. Please be sure to read them – it provides vital recommendations for your puppies & kittens well-being and quality of life. If your pet has passed the puppy/kitten stage they will still require their vaccines to be updated. Any time a new vaccine is introduced to your pet's immune system it will need to be boosted in a 3-4 week time frame. Please keep that in mind so your pet can be as protected as possible. *

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WELLNESS EXAMS: If you are requesting that we vaccinate your pet please be advised by state law we can only vaccinate pets healthy enough to receive a vaccine. To determine if they are healthy we require a physical exam performed by our Veterinarian to ensure we are only vaccinating healthy pets. If we administer vaccines you will be charged for a Wellness Exam ($52.50) annually as well as the needed vaccinations/test — it will not matter when your pet was last seen by another Veterinarian at another facility, we are establishing a doctor-client-patient relationship. If one of our Doctors has examined your pet over 60 days ago we will require a Brief Exam, again, to ensure your pet is healthy enough to receive a vaccine. Other fees will apply for pets that are Sick or Injured as well as for Work-In Appointments or Emergencies. *

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SURGICAL/DENTAL POLICY: All procedures (surgical and dental) are performed in the morning to allow enough time for your pet to recover as much as possible before you take them home. We make every effort to ensure that we’ve reserved a proper amount of time, scheduled staff accordingly and in some cases ordered special equipment/tools for your pet’s procedure. Because we are reserving time and staff for your pet’s procedure we require a 20% deposit at the time your pet’s procedure is scheduled. The deposit will be applied to the balance due at discharge. The deposit will be refundable if you give us at least 48-hour notice of the cancellation. For more complex surgeries (orthopedics and ear croppings) we require a 72-hour notice. Leaving a voicemail on the weekend for a Monday or Tuesday procedure will not suffice as an appropriate notice given. If you do not cancel within that time and/or do not show up for your pet’s scheduled procedure the deposit will be forfeited. *

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PHARMACY POLICY: According to Virginia Statues (Veterinary Pharmacy Section 54.3303), for us to dispense prescriptions we must have an established doctor-client-patient relationship. In order for us to establish that relationship we MUST perform a physical exam annually on your pet to dispense, refill medication or write prescriptions. Due to certain health concerns we may also require diagnostic lab work in order to dispense prescriptions as well. This includes prescription diet foods. In addition, once a prescribed medication leaves our building we are no longer able to take back the medication for a credit/refund. Federal law stipulates that any medications that leave the pharmacy may not be returned for reuse due to potential safety concerns that include, tampering, incorrect storage and contamination. CHESTER ANIMAL CLINIC will not accept medications for return under any circumstances. NOTE: When you purchase heartworm, flea & tick medications from our in-house pharmacy you will be getting the best value and product. Check our pricing before shopping as you’ll find we are able to offer FREE dose(s) on quantity purchases. We are also pleased to offer our own on-line pharmacy where you will find some regularly prescribed medications. Our on-line pharmacy carries various brands of heartworm, flea & tick medication thyroid medication, prescription diet food, etc. Once your product is ordered and approved, it will be mailed directly to you—and also supported by the manufacturer. If you order the wrong product you will also not be allowed to return the product or receive a credit for the prescription. *

I have read and understand.

ONLINE PHARMACIES: Be advised if you choose to purchase from an on-line pharmacy other than ours you will have to pick up the prescription from our office and mail or fax the prescription directly to them; we do not verbally approve, mail, fax or email prescriptions to on-line pharmacies. In our experience we have found gross mistakes and errors in prescriptions coming from internet pharmacies and do not feel confident that you will receive the quality product we are prescribing. Zoetis, Elanco, and Merck will NOT support products purchased from other on-line pharmacies or retail shops (other than directly purchased from a licensed Veterinarian. *

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ELECTRONIC NOTIFICATIONS: As a continued effort to “go green" we will be using email, text message and push notifications to send your pet’s reminders. These reminders will include medical service reminders, inclement weather updates, policy changes, appointment reminders, and any other pertinent notifications. By initialing this policy you understand that you will be receiving notifications by email, text and/or push notifications. If you decide to opt out of this system you understand that you will no longer receive notifications OF ANY KIND from Chester Animal Clinic. We will be posting information on the Chester Animal Clinic FaceBook page regarding inclement weather notifications and hours changes due to inclement weather. *

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CHESTER AC APP: We are pleased to offer an app, the Chester AC app, to all of our clients with a smart phone. It is free and available through the App or Google Play Store. This app send notifications to remind you of your pet’s appointments, medical service reminders, allows you to request prescription refills and prescription foods. This app also offer a loyalty program, you earn a paw print for every $100 spent for medical services (with no expiration date). After 16 paw prints are collected you earn a $50 credit on your account to be used at your next medical appointment. You can text us and email us directly through the app, send us your favorite pet selfies, have access to Veterinary Information Network on pet health, apply for Scratchpay (a payment plan option available at Chester Animal Clinic), direct link to Poison Control and a link to our on-line pharmacy, VetSource. *

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As we have made every effort to outline our policies and provide them to you in a reasonable time to read them, we expect that you will, by the time of check-in, have read them, understand them and able to follow what we need to provide your pet(s) with superior care. Again, we thank you for the privilege of caring for your special pet. We welcome all suggestions in our quest to remain the best facility in the state of Virginia and beyond. We are here to serve you and your pet and will do our best to make this a wonderful experience for both of you. *

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