We have moved to our new location,
4405 Poindexter Street, Walkertown, North Carolina.
Come visit!

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Our Practice
Services
New Clients
- New Client Form
Resources
Contact Us
- Areas We Serve

Welcome new clients and patients!

We know your pet’s health is important and we thank you for trusting us to care for them.

To help us provide the best care possible, please take a few moments to fill out this form completely. Thank you for your cooperation in letting us assist you.

"*" indicates required fields

Pet Owner/Client Information:

First Name**

Last Name**

Main Phone**

Address**

Street Address* City* State* Zip Code*

Spouse's Name

Spouse's Phone

Other

Employer

Phone

Driver’s License number

Date of Birth

MM slash DD slash YYYY

Email Address

How did you learn about us?

If personal referral, whom may we thank?

Pet Information: (For more than one pet, ask for additional pet form)

Pet's Name

Species

Breed

Color

Microchip #

Date of Birth

MM slash DD slash YYYY

Age

Sex

Neutered or Spayed

Pet’s Diet

Any special diets

List current medications and/or medical conditions

List any previous illnesses or surgeries

Does your pet have any allergies?

Has your pet had heartworm testing? On prevention medication (what kind)

Is your pet on flea and tick prevention (what kind)

Please check any symptoms your pet is currently showing

Coughing

Sneezing

Breathing problems

Diarrhea

Constipation

Urination decrease/increase

Scooting

Vomiting

Appetite loss

Change in activity level

Behavioral changes

Limping

Shaking head or ears

Scratching or itching

Change in thirst

Rash

Loss of balance/weakness

Unusual mass

Eye problems

Cut or injury

Describe Any Other Areas of Concern:

300 words max

I Approve My Pet’s Picture and Their First Name to be Used in Social Media

Yes

No

Please bring in a stool specimen so we can check for parasites

Authorization**

I authorize the veterinarian to examine, treat, or prescribe for my pet(s). I assume responsibility for all charges incurred in the care of the animal(s). I also understand that all professional fees are due at the time services are rendered.
Returned check fee: $20

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Our Practice
Services
New Clients
- New Client Form
Resources
Contact Us
- Areas We Serve

Our Practice
Services
New Clients
- New Client Form
Resources
Contact Us
- Areas We Serve

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