Name* First Last Email* Primary phone*Secondary phoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Place of Employment:*Drivers License number*Social Security#How did you hear about us?* Friend/Family/Neighbor Blue Ridge Veterinary Associates Team Member Google Yelp Facebook Website Advertisement Rescue Group Community Event Saw building/sign Other Who? So we can thank them!OtherRescue GroupPet InformationName*Color/Description*Breed*Sex:*MaleFemaleNeuteredSpayedIs your pet microchipped?*YesNoAdd another pet?*YesNoName*Color/Description*Breed*Sex:*MaleFemaleNeuteredSpayedIs your pet microchipped?*YesNoVaccination History (Date and Type of Last Vaccination)*Please Check (+) any symptoms or problems that you have noticed about your pet.* Behavioral Problems Breathing Problems Coughing Diarrhea Depressed Eye Issues Lack of Appetite Limping Scooting Scratching Shaking Head Sneezing Thirst and /or Urination Increased Vomiting Weakness Other Other*Please list other person(s) authorized to seek care or make medical decisions for your pet.We occasionally receive calls from individuals who have found an animal . If your pet is found by someone, please let us know how you would like us to act. We will not give out personal information without permission.* Please give out my number and/or address to the person who finds my pet, they can contact me directly. I would like to be contacted by Patton Chapel Animal Clinic d irectly. Please don’t give out my personal Information without talking directly to me first. How do you wish to pay for this visit?* Cash Check Visa Master Card Discover In the extraordinary event payment is not received at time of service, please be advised there will be a fee of $25.00 charged to set up payment plans for open balances. Additionally, a 2% service fee will be charged each month on all accounts over 30 days old, until paid in full.