NEW PET WELCOME FORM

Address: 10618B Providence Rd, Charlotte, NC 28277

Contact: (704)844-8387

Pet's Name:*

Name*

Pets NameLast Name

Would you like to share how your pet got his/her name?

DOB or approximate age:*

Dog/Cat/Other

DogCatOther

Breed*

Color*

Unusual Markings

Sex*

Male (Intact)Male (Neutered)Female (Intact)Female (Spayed)

Does your pet have a microchip?*

YesNo

Microchip number:

Name & phone number of previous Veterinarian(s) where past records may be obtained:*

If your pet has been treated for an illness in the past year, please explain:

List any previous surgeries:

If your pet has ever had a reaction to a vaccine or medication, please explain:

List any medications your pet is currently taking (including heartworm, flea & tick prevention):*

Is your pet...

IndoorOutdoorIndoor/Outdoor

Does your pet get anxious (select all that apply):

Around other animalsIn the carAt the vet

Do specific procedures cause anxiety (select all that apply)?:

Nail trimAnal sac expressionExam of face/earsOther

Do children live in the home?

YesNo

Does your pet:

GroomBoardGo to daycareGo to dog parks

Do you have pet insurance?

YesNo

Which company?

Anything else we should know about your pet or your approach to your pets healthcare?

I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF THIS ANIMAL. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT. I ALSO GRANT YOUR VETERINARY HOSPITAL PERMISSION TO POST MY PET'S PICTURE, STORY, AND MEDICAL INFORMATION ON SOCIAL MEDIA.

Owner or Responsible party signature (Must be at least 18 years old):*

Date*

Date

Printed Name*