Compassionate Care Veterinary Hospital of Charlotte

To ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us. You will be asked to sign and date a printout of this form when you come in for your first appointment.

Your Name
Street Address
City, State, Zip
Home Phone
Work Phone
Occupation
Employer	Name, address, phone
Mobile Phone
E-mail
Alternate Contact:
Alternate Contact Name
Alternate Contact's Relation to You
Alternate Contact's Phone
Alternate Contact's Street Address
Alternate Contact's City, State, Zip
Alternate Contact's Occupation
Employer	Name, address, phone
Is this person authorized to make decisions about your pet’s health? Yes No
How did you first learn of our hospital?
Were you referred by someone?
Do you consider your pet	Part of the family Just a pet
# of Pets in Your Household
Pet Information:
Pet Name
Species	Dog Cat Other
If Other Species
Breed
Description/ Color
Sex	Male Female
Date of Birth
Neutered/Spayed?	Yes No
Microchipped?
Previous Hospital/ Vet	name, address, phone
Groomer	name, address, phone
Vaccination Dates	Lyme DHPP Bordatella Rabies FVRCP FELV
Current Medications	name, dosage
Prior Illness/ Accidents
Prior Surgery/ Dentistry
Disclaimer (read-only)	PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED • To prevent the spread of infectious diseases and parasites, we recommend animals be current on all vaccines. Pets with fleas will be treated with a topical or oral flea medication on admission, and the prescription price will be included in the invoice. I authorize administration of vaccines and parasite control as needed for my pet(s). • In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Compassionate Care Veterinary Hospital of Charlotte, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. At your request, we will gladly discuss cost of services and/or prepare a written estimate for recommended procedures. Professional fees are due at the time services are rendered. Deposits may be required for pets being admitted. • I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted, if possible, prior to treatment should complications occur.
When you are finished, click submit to send the form information


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