Wellness Appointment Request Form

Thank you for your interest in a Wellness appointment at the Sandhills Spay Neuter Veterinary Clinic (SNVC), located at 5071 US Hwy 1 N, Vass NC 28394!

Please fill out the information below. At this time, all wellness appointments are scheduled on Thursdays. We do require a $25.00 deposit for your wellness apppointment. This deposit will be used towards your scheduled visit. This deposit is NON-REFUNDABLE if your appointment is canceled/rescheduled with less than a 48 hour notice OR if you do not show up for your scheduled appointment.
Wellness Appointment Request Form

Sandhills Spay Neuter Veterinary Clinic - SNVC
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are you currently receiving financial assistance such as Medicaid, Food and Nutrition, WIC, etc.?
If you answered YES to receiving financial assistance, please provide a copy of your benefits letter that includes a current date range.

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Patients Name
Is your Pet spayed or neutered?
Do you have a Male/Female/Cat/ or Dog
Patients Color and Breed
Patients Approximate Weight
Patients Approximate Age (weeks, months, or years)
You can now Take a Photo or Upload a Photo of your Pet for their medical record!
Patient Photo Upload

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Are you requesting an appointment for more than one Pet? If you answer yes, please complete a new form per pet.
Has your pet ever had vaccines or seen a veterinarian
Please provide a copy of your Pets vaccine history if available

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*** ALL WELLNESS VISITS INCLUDE A $35.00 EXAM FEE ***
Please check which services you would like at the time of your Pets wellness appointment
Do you have any additional information on your Pet to provide?

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Appointment Deposit

includes 4% merchant fee ($1.00)

$26.00 Quantity

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human
Should be Empty:

Thank you for your interest in a Wellness appointment at the Sandhills Spay Neuter Veterinary Clinic (SNVC), located at 5071 US Hwy 1 N, Vass NC 28394!

Wellness Appointment Request Form

My Products