Owner's Name*

First Last

Primary Phone*

Email*

What is your preferred method of contact?*

Phone
Text message
Email

Vaccination reminders will be sent to you via e-mail

Spouse/Partner/Co-Owner's Name

First Last

Spouse Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer’s Name and Address

Spouse/Other’s Employer’s Name and Address

How did you learn of our hospital?*

Who can we thank?*

Which one?*

Other information the office should know?

Do any family members have peanut allergies?*

Yes
No

List 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.*

Yes
No

Pet Information

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male
Female

Spayed/Neutered?

Yes
No
Not sure

Do you have a second pet?

Yes
No

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male
Female

Spayed/Neutered?

Yes
No
Not sure

Do you have a third pet?

Yes
No

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male
Female

Spayed/Neutered?

Yes
No
Not sure

Do you have a fourth pet?

Yes
No

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male
Female

Spayed/Neutered?

Yes
No
Not sure

Do you have a fifth pet?

Yes
No

Pet's Name

Species

Breed

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Birth Date

Sex

Male
Female

Spayed/Neutered?

Yes
No
Not sure

FEES 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/Check
Visa
MasterCard

Staffing 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*