Carr Veterinary Hospital

1433 Hwy. 68N
Oak Ridge, NC 27310

(336)643-6115

carrvethospital.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
Spouse/Other Parties
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Our pet(s) is a:
Family member
Child's pet
Backyard pet
Hunting/Working animal


How did you learn of our practice?
Drove By
Yellow Pages
Internet/Website
Newspaper
Previous Client (please note below)


If referred by a previous client, whom may we thank?

Please list any previous serious illnesses or surgery (explain):

Please list any known allergies to vaccines or medications:

Please list any medications or special diets your pet receives :

Please indicate your choice of payment type:
Cash/Check
Visa
Mastercard
Discover
American Express
CareCredit


If paying by check, please provide driver's license number:

Would you like to be present during treatment of your pet?
Yes
No
Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Carr Veterinary Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Carr Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. I hereby grant Carr Veterinary Hospital and its agents the right to use images of myself or my pet(s) in connection with its promotional materials in any and all media including printed material, internet and film. Any such use of images will be anonymously without any owner and patient name or identifying information. The copyright of any images collected are solely owned by Carr Veterinary Hospital.
I have read this statement and -
I Agree
I Disagree



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