Apple Valley Animal Hospital

1207 Cedar Creek Grade
Winchester, VA 22602



Advanced Directive


New Clients, you will need a Client Information, Vaccination Consent, Advance Directive and Staff Hours form filled out prior to your first appointment!


Please forward all previous records to



Advanced Directive Form

If there is an unexpected or life-threatening situation involving any of my pets, I would like the following actions taken:

I give permisson for the doctors and support staff of Apple Valley Animal Hospital to initiate life-saving emergency care and treatment for my pets. I understand that I am financially responsible for these treatments, and I am aware that intial stabilization fees could be up to $500.00.
After the initial stabilization, I will receive an estimate for the rest of my pet’s care... I would like the following pets omited from this directive:

I agree to the above statement (OPTIONAL - 1 of 2 choices) (required)


I do not wish for any heroic care to be performed on any of my pets without my permission and a written estimate. I understand in emergency situations time is of the essence, and by checking this box I will be delaying my pet’s care.
I agree to the above statement (OPTIONAL - 2 of 2 choices) (required)


Client's Name: (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
County (required)

Client's Phone: (required)
Phone TypePhone Number (required)

In consideration for following my wishes, I hereby release Apple Valley Animal Hospital, its staff, and authorized representatives from any and all liablity that may have subsequently accrued to me, as a result of honoring this directive. I declare that the doctors and staff of the Winchester Animal Hospital are acting in accordance with my wishes. I certify that I am the legal owner or the duly authorized agent for the owner of the pets listed on my record. I understand that my wishes may be carried out immediately upon my signing this agreement. I assume full responsibility for applicable fees as listed above. I fully understand the foregoing provisions. I understand that this advance directive will be honored until I wish to make changes to it.

Any decision I declare on the phone shall supersede my written directives.
I agree that I have read all of the information provided on this form and that all of the above information I have provided is true. (required)

I agree
I disagree

Today's Date: (required) :

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