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Home
$25 New Client Exam
About
Our Veterinarians
Our Careteam
Testimonials
Photo Gallery
Careers
Reviews
Services
Wellness & Vaccinations
Premier Care Plans
Nutrition & Weight Management
Allergies & Dermatology
Dentistry
Diagnostics
Surgery
Critical Care
Urgent Care
Boarding
Hospice Care
Phovia Light Therapy
Pain Management
Header Logo
Resources
Request an Appointment
Boarding Registration
Request A Refill
Online Store
Links
Appointment Policy
Blog
Contact
!Let's Talk! Button
Call Us! 252-504-2097
Let’s Talk! 252-504-2097
New Patient Information
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Information about you and your pet!
Client Information:
Your First Name:
*
Your Last Name:
*
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Australia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cabo Verde
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Guernsey
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
Saint Helena
Saint Pierre & Miquelon
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
US Minor Outlying Islands
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Home Phone:
Cell Phone:
Work Phone:
Email Address
*
We can email exam report cards and important notices.
Spouse Name:
Spouse Cell:
Spouse Work:
Preferred Contact Method?
Home
Cell
Email
Text Message (Option coming soon)
How did you hear about us?
Google
Yahoo
Yelp
Other Search Engine
In the Neighborhood/Sign
Here with another pet
Friend/Relative/Neighbor
Other
Other (please name):
Are you interested in our Pet Health Plans?
Yes
No
Financial Information:
Credit Card:
Visa
M/C
Discover
American Express
Care Credit
Cash
I have Pet Health Insurance
I do not have Pet Health Insurance (Please tell me about it!)
I hereby authorize the doctors and staff to diagnose, prescribe for, and treat the above described pet. I assume all responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time services are rendered. In the case of hospitalization, I will be required to leave a substantial deposit. The remaining balance must be paid in full at the time of discharge of the pet. I authorize photos and video to be taken of my pet’s care for training, website, and educational purposes.
Please present a valid drivers license or photo id at the time of check-in.
Pet Information:
Pet Name:
Birth date/Approx age:
Type of Pet:
Dog
Cat
Bird
Other
Breed:
Color:
Sex:
Male
Female
Neutered/Spayed:
Yes
No
Indoor/Outdoor:
Indoor
Indoor/Outdoor
Is your pet Microchipped?:
Yes
No
Where did you get your pet?:
When did you get your pet?:
Approx. age when acquired:
Are you 65 or older?:
Yes
No
Are you a First Responder?:
Yes
No
Past Veterinarian:
Would you like us to contact past vet for medical history?:
Yes
No
Approx. date of last veterinary examination:
Last vaccinations (date):
How many, and what type of pets do you own?
Dog(s):
Cat(s):
Bird(s):
Other (specify):
Kindly list any previous medical or surgical problems and current medications:
Is your pet currently taking Heartworm Preventative?
Yes
No
Name of Meds.:
What flea and tick protection are you currently using on your pet(s)?
What brand of food is you pet currently eating?
Does your pet get any table scraps and how often?
Describe your pet’s temperament (personality):
Reason for visit:
The individuals listed below are authorized representatives to act on your behalf in cases dealing with the pet listed above. They are authorized to obtain medical information regarding your pet, to admit and pick up your pet from our facility, and give verbal and/or written authorization to perform medical services and procedures. The individuals listed below are required to show photo identification when acting as your authorized representative.
Contact #1 Name:
Contact #1 Relationship:
Contact #1 Contact Number:
Contact #2 Name:
Contact #2 Relationship:
Contact #2 Contact Number:
Contact #3 Contact Name:
Contact #3 Relationship:
Contact #3 Contact Number:
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Please do not fill in this field.
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