Vet Accepting New Patients in Cary, NC

Owner's Name*

Home Phone*

Cell Phone

Email*

Address*

Address line 2

City*

State / Province / Region*

ZIP / Postal Code*

Co-owner's Name (if any)

Co-owner's Phone

Co-owner's Email

Is there anyone else whom you give authorization to make medical decisions for your pet, or is allowed to drop-off/pick-up your pet? Please list their names and telephone numbers.

How did you find out about our practice?*

Driving By
Personal Referral
Internet Search / Website
Postcard by mail
Clipper Magazine
Carolina Preserve Magazine
Other

If Other, please specify:

If Personal Referral, who can we thank for this referral?

Do you already have your first appointment scheduled with us?*

Yes
No, please contact me to schedule my first appointment
No, I will contact you when I would like to schedule an appointment

If Yes, what is the date of your first scheduled appointment?

Pet's Name*

Species*

or if other species, please list

Breed (if known)

Color

Date of Birth or Age (if known)

Sex

Male
Female

Special Identification (tattoo, microchip, etc.). If your pet has a microchip, please include the microchip number.

Previous Veterinary Practice (if any)

Where is it located? (City and State)

Do we have your permission to contact your previous veterinary practice to obtain your pet's medical and vaccine history?

Yes
No (If possible, please email a copy to [email protected] or fax at 919-469-4161 before your first appointment.

Does your pet have any known allergies to vaccines or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Financial Policy: I understand that full payment is due at time of service. Accepted forms of payment include cash, check, Visa, Mastercard, Discover, and Care Credit. An estimate can be provided upon request. Any checks returned for insufficient funds will be assessed a fee that will be added to the balance due. Balances not paid within 30 days will begin to accumulate a late payment interest fee of 1.5% per month.*

Appointment Cancellation Policy: If you need to cancel or reschedule an appointment, we respectfully request a 24 hr notice. Missed appointments, or appointments cancelled without 24 hr notice, will incur a fee of $30 for veterinary appointments, or $50 for surgical appointments.*

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