New Client Form Download and Print Form Owner's Name* First Last Primary Phone*Email* What is your preferred method of contact?*PhoneText messageEmailVaccination reminders will be sent to you via e-mailSpouse/Partner/Co-Owner's Name First Last Spouse PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer’s Name and AddressSpouse/Other’s Employer’s Name and AddressHow did you learn of our hospital?*Saw Our Hospital / LocationGoogle (or other search)FacebookOnline Review SiteClient ReferralWho can we thank?*Which one?*Other information the office should know?Do any family members have peanut allergies?*YesNoList names*Photo Consent: Do we have your permission to share you pet(s)' image and story on social media, our website and other forms of related media? Your name and personal information will never be shared.*YesNoPet InformationPet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date Date Format: MM slash DD slash YYYY SexMaleFemaleSpayed/Neutered?YesNoNot sureDo you have a second pet?YesNoPet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date Date Format: MM slash DD slash YYYY SexMaleFemaleSpayed/Neutered?YesNoNot sureDo you have a third pet?YesNoPet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date Date Format: MM slash DD slash YYYY SexMaleFemaleSpayed/Neutered?YesNoNot sureDo you have a fourth pet?YesNoPet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date Date Format: MM slash DD slash YYYY SexMaleFemaleSpayed/Neutered?YesNoNot sureDo you have a fifth pet?YesNoPet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date Date Format: MM slash DD slash YYYY SexMaleFemaleSpayed/Neutered?YesNoNot sureFEES ARE DUE AT THE TIME SERVICES ARE RENDERED We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor. Preferred Payment Method*Cash/CheckVisaMasterCardStaffing Hours Cary Street Veterinary Hospital has business hours as follows: Monday through Friday - 7:30am to 6:00pm We are closed weekends and holidays. Doctor's hours are from 8:00am to 6:00pm Monday through Friday. This is to inform you that we have no on-duty, continuous medical staff beyond the doctor's hours posted. I have read this form, and I am aware of the above staffing hours. * I have read the above statement, and I am aware of the above staffing hours. Missed Appointment Policy At Cary Street Veterinary Hospital, our goal is to provide the best in veterinary care for your pet. In order to do so, we see patients by appointment only; this ensures that we will have sufficient time to examine your pet and to discuss your pet’s condition and treatment options. Appointments are in high demand, and when they are missed, we lose that opportunity to offer timely medical care to a patient in need. In order to be respectful of the medical needs of all of our patients, we ask that you keep your appointments, arrive on time, and that you notify us at least 24 hours in advance if you will be unable to make your scheduled appointment. Arriving 15 minutes late without notice and late cancellations will also be considered a missed appointment. 1st missed appointment - Our staff will call to ensure the wellbeing of you and your pet in addition to rescheduling your appointment. 2nd missed appointment - We will call you to let you know that this is your second missed appointment and that a missed appointment fee will need to be paid prior to receiving any new services, prescriptions, or food. 3rd missed appointment - We will call you to let you know that this is your third missed appointment and that a missed appointment fee will need to be paid prior to receiving any new services, prescriptions, or food. Additionally, all future exams will require pre-payment in order to schedule an appointment. $60 for a missed appointment with a Doctor $30 for a missed appointment with a technician* I have read and understand the above missed appointment.policy Signature*