

Vienna

Surgery: (703) 242-6000
vienna@vscvets.com
Rehab: (703) 242-4743
rehab@vscvets.com



Leesburg

Surgery: (703) 771-2100
leesburg@vscvets.com
Rehab: (571) 206-1340
rehab@vscvets.com



Gaithersburg - Now Open

Surgery, Neurology & Internal Medicine:
(240) 641-6350
gaithersburg@vscvets.com

Home
ABOUT US
Surgery
Sports Medicine & Rehab
Neurology
Internal Medicine
Pet Owners
Primary Vets
Contact Us
BOOK APPOINTMENT

Home
ABOUT US
Surgery
Sports Medicine & Rehab
Neurology
Internal Medicine
Pet Owners
Primary Vets
Contact Us
BOOK APPOINTMENT

Client Registration Form

Save time during your first appointment! Complete your client registration form online before your visit.

Client Registration Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

Download Form Now

Date

Client Registration

Owner *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell *

Home

Work

Email *

Secondary Contact

Contact

Active Military?

Yes
No

Provide military ID *

How did you hear about us?

Friend/Family
Event
Magazine
Google
Yelp
Facebook
Internal Referral
Veterinary Professional (please fill fields below)
Other

Veterinarian Name *

Hospital Name *

Other *

Patient Registration

Name of Pet *

Nickname *

Species *

Breed *

Color *

Date of Birth

Sex *

Approximate weight at 2 years *

Occupation *

Cats: FIV/Felv tested? *

Yes
No

If so, when *

Results *

Cats/Dogs: Heartworm tested? *

Yes
No

If so, when *

Results *

Does your pet have any allergies? *

Yes
No

If so, allergic to *

Primary Care Veterinarian

Veterinarian’s Name

Hospital Name

Phone Number

Specialist Seen (Previously)

Veterinarian’s Name

Hospital Name

Phone Number

Specialist Seen (Previously)

Veterinarian’s Name

Hospital Name

Phone Number

Preferred Pharmacy

Pharmacy’s Name

Pharmacy’s Location

Phone Number

Pet History

Why are we seeing your pet today?

Under what circumstances did you first notice the condition and how long ago?

Does anything seem to aggravate the condition and has it gotten worse or better over time?

Have radiographs been taken for this current condition? *

Yes
No

If yes, where? *

Has your pet had recent bloodwork within the last 6 weeks? *

Yes
No

If yes, where? *

Please describe your pet’s diet

Please mark any signs or problems you have noticed in your pet: *

Skin Problems
Increased Thirst
Breathing Problems
Staring into Space
Increased Urination
Coughing/Gagging
Exercise Intolerance
Diarrhea/Vomiting
Wheezing
Fainting/Collapsing
Change in Appetite
Tongue turning blue
Weakness
Weight Loss
Bleeding Problems
Loss of Balance
Allergies
Limping
Difficulty on Stairs
Trouble Sleeping
Difficulty Getting Up/Down Furniture
Loss of Muscle Mass
Seizure
Difficulty getting in/out of car
Lyme Disease
Circling/Pacing
Other

Limping *

Right
Left
Back
Front

Other *

Is your pet’s rabies vaccine up to date? *

Yes
No

Do you feel your pet is currently at a healthy weight? *

Yes
No

If yes, when and where? *

Please list all current medications below:

Medication Name

Dose Given

Frequency

Doctor Prescribed By

Medication Name

Dose Given

Frequency

Doctor Prescribed By

Medication Name

Dose Given

Frequency

Doctor Prescribed By

Medication Name

Dose Given

Frequency

Doctor Prescribed By

Did any of these medications help? *

Yes
No

If yes, please describe *

Has your pet had any previous surgeries? *

Yes
No

If yes, please describe *

Has your pet had any previous complications with anesthesia? *

Yes
No

If yes, please describe *

When was your pet’s last meal given? *

Date

Time

Are you aware of any metal such as implants or hardware or in your pet? *

Yes
No

If yes, please describe *

Is there any other pertinent information you feel the doctor should know?

Have you or anyone in your household had any cold or flu-like symptoms in the last 14 days including a fever? *

Yes
No

Have you or a member of your household traveled out of the country in the last 14 days? *

Yes
No

Have you or a member of your household tested positive for COVID-19? *

Yes
No

Is your pet *

Indoor
Outdoor
Indoor and Outdoor?

If you pet goes outside, has your pet been within 6 feet of other pets or people not living in the household? *

Yes
No

Has your pet shown any respiratory signs such as coughing, sneezing, nasal discharge or fever in the last 7 days? *

Yes
No

Signature *

Clear Signature

Date *

Message

Book an Appointment Today!

We are proud to serve the pets in Vienna, VA, Leesburg, VA, Gaithersburg, MD, and the surrounding areas in the DMV.

Please call (703) 242-6000 to schedule an appointment at our Vienna location.
Please call (703) 771-2100 to schedule an appointment at our Leesburg location.
Please call (240) 641-6350 to schedule an appointment at our Gaithersburg location.

Book Appointment

Have Questions?

Reach out to us! Our team is here to answer any questions or concerns you may have.



Vienna



Surgery

VSC at Hope Advanced Veterinary Center
140 Park Street SE
Vienna, VA 22180



Surgery & Rehabilitation

124 Park St. SE (Lower Level)
Vienna, VA 22180



Contact Details

Phone | Surgery: (703) 242-6000
Fax: (703) 242-4770
vienna@vscvets.com

Phone | Rehab: (703) 242-4743
rehab@vscvets.com



Opening Hours

Monday – Friday: 7:00 am – 5:00 pm
Saturday – Sunday: Closed



Leesburg



Surgery

VSC at The LifeCentre
165 Fort Evans Road NE
Leesburg, VA 20176



Rehabilitation

VSCR at The LifeCentre West
134 Fort Evans Rd. NE
Leesburg, VA 20176



Contact Details

Phone | Surgery: (703) 771-2100
Fax | NEW! : (571) 377-8996
leesburg@vscvets.com

Phone | Rehab: (571) 206-1340
Fax: (703) 662-9665
rehab@vscvets.com



Opening Hours

Monday – Friday: 7:00 am – 5:00 pm
Saturday – Sunday: Closed



Gaithersburg



Surgery, Neurology & Internal Medicine

Specialists at Veterinary Surgical Centers
9701 Washingtonian Blvd
Gaithersburg, MD 20878



Contact Details

Phone: (240) 641-6350
gaithersburg@vscvets.com



Opening Hours

Monday: 8:00 am – 6:00 pm
Tuesday: 8:00 am – 6:00 pm
Wednesday: 8:00 am – 6:00 pm
Thursday: 8:00 am – 6:00 pm
Friday: Closed
Saturday: Closed
Sunday: Closed

For media and marketing inquiries, email marketing@vscvets.com.

Get in Touch

Name *

First

Last

Email *

Phone

Which services are you interested in learning more about? *

Surgery
Rehabilitation
Neurology
Internal Medicine
Diagnostic Imaging
Other

If other, please specify. *

Which location are you interested in visiting? *

Vienna, VA
Leesburg, VA
Gaithersburg, MD

How can we help you? *

Name

© 2025 Veterinary Surgical Centers | Powered by PetDesk | Privacy Policy | Accessibility Statement | Sitemap


Vienna
Gaithersburg