Name *

First

Last

How Did You Hear About Us?

Other

Emergency Contact Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

I consent to SMS reminders for appointments, bloodwork results, and clinic communication. *

Yes
No

Emergency Contact Phone

Work Phone

Email *

Comments

Patient Information

Patient Name *

Patient Sex *

Patient Species *

Patient Breed *

Patient Color *

Is Your Pet Up-to-Date on Rabies? *

Yes
No

Patient Rabies #

Is Your Pet Currently on Prevention? *

Yes
No

What Prevention Is Your Pet On? *

Example: Bravecto Flea & Tick, Sentinel Spectrum Heartworm & Intestinal Parasite

the for doctors

List Any Current Medications Your Pet Is On:

Allergies

Birthdate or Estimated Age *

Age Is Estimated *

Yes
No

Do You Have a Current or Past Family Veterinarian? *

Yes
No

Current or Past Family Veterinarian Office *

We may need this information to get pertinent records.

Upload a Picture of Your Pet

Click or drag a file to this area to upload.

THIS IS NOT REQUIRED BUT RECOMMENDED FOR OUR RECORDS

I Give Permission to Our Office to Post Social Media Pictures of My Pet *

Yes
No

PLEASE READ THE FOLLOWING CAREFULLY:

Payment IN FULL is due at the time your pet is discharged.
I will be provided with a written estimate of charges.
A 100% deposit will be required if your pet is hospitalized. If your pet needs to have surgery or a procedure, the HIGH end of the estimate must be paid upfront.
I authorize the veterinarians to perform treatment & diagnostics for my pet.
I assume responsibility for ALL charges incurred in the care of this animal.
We have a strict policy to not allow returns of medications once they have been dispensed and removed from the hospital.

Payment IN FULL is due at the time your pet is discharged. I will be provided with a written estimate of charges. A 100% deposit will be required if your pet is hospitalized. If your pet needs to have surgery or a procedure, the HIGH end of the estimate must be paid upfront. I authorize the doctors to perform treatment & diagnostics for my pet. I assume responsibility for ALL charges inccured in the care of this animal. We have a strict policy to not allow returns of medications once they have been dispensed and removed from the hospital.

I Agree to the Above Statements

Appointment Type *

This Is an Urgent Care/Emergency Visit/Sick Patient
This Is A Wellness Visit

Signature *

Clear Signature

Use your mouse or finger to draw your signature above

I Have Another Pet to Add - Wellness Only Please

Yes
No

If You Have Another Sick/Urgent/Emergent Case - Please Fill Out the Entire Form Again Once Submitting

Phone

Email

Hours

Phone

Phone

Fletcher, NC

New Client Form

New Client Form

New Client Form

Patient Information

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Location

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Hours