NEW CLIENT AND NEW PET WELCOME FORM

10618B Providence Rd, Charlotte, NC 28277

(704)844-8387

Welcome to the Central Providence Veterinary Hospital family - we are glad you are here! At CPVH, you will experience high quality up-to-date pet healthcare delivered by a caring and compassionate team that makes partnering with you to improve the health of your pet and the strength of your bond our highest priority. Please let us know how we can fulfill our mission for your family.

Our mission: Healthier Pets, Happier People.
Our Values: Quality, Kindness, Convenience & Safety.

Thank you for taking the time to fill this form out as completely and accurately as possible.

Co-Owner or Responsible Party Information:
Are you the:

OwnerCo-OwnerResponsible party
Name*
Name and relationship to owner
Address*
Address if different
City/State/Zip*
City/State/Zip
Primary Phone*
Primary Phone
Secondary Phone
Secondary Phone
Email*
example@example.com
Email
example@example.com
How would you like to be addressed?

Mr.Mrs.Dr.First nameOther
Contact preference (Please mark 1, 2, 3): Phone Call
Contact preference (Please mark 1, 2, 3): Text message
Contact preference (Please mark 1, 2, 3): E-mail
How did you hear about us?
Should we share a referral discount with any specific person?
* If alternate individuals are permitted to make medical and/or financial decisions for your pets, please list their name and contact information here:
Alternate's Name:
Alternate's Contact (Phone number):
Please enter a valid phone number.
Pet's Name:*
Would you like to share how your pet got his/her name?
DOB or approximate age*
Dog/Cat:*

DogCatOther
Breed
Color
Sex

Male (Intact)Male (Neutered)Female (Intact)Female (Spayed)
Unusual Markings
Does your pet have a microchip?

YesNo
Microchip number:
Name & phone number of previous Veterinarians 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 (select all that apply):

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)*

Clear
Date*

MonthDayYear
Date
Printed Name*
Should be Empty:

* If alternate individuals are permitted to make medical and/or financial decisions for your pets, please list their name and contact information here: