New Client Form | Charleston Harbor Veterinarians

The following form will help us meet the needs of you and your pet. We look forward to meeting you both very soon!

Please note we require a deposit to reserve your first appointment. You can read about this policy here: https://charlestonharborveterinarians.com/new-client-deposit-policy/

Client Information

Information about you

First Name

Last Name

Mobile Phone

Other Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are there other individuals authorized to make medical decisions for your pet(s)?

Yes

First Name

Last Name

Mobile Phone

Relation

First Name

Last Name

Mobile Phone

Relation

What things are most important to you about your experience with your veterinary clinic?

Which best describe your decision making process for your pets' medical care? (there is no right or wrong answer)

I want the best medicine available, regardless of cost

I would like the doctor to give me their recommendation and not overwhelm me with options (make it simple, I trust you)

I want to know the options and for the doctor to help me come to a decision based on my feedback (I trust you, but give me some options)

I would like the options laid out with all details and be given time to make my own decision

I would like to be offered the most cost effective option for my pets care

Is there anything else we should know that will help us serve you best?

Who can we thank for referring you or how did you find out about Charleston Harbor Veterinarians?

Do you have a preferred doctor and/or team member?

Deposit Agreement (for new clients only, not new pets under existing clients): I agree to pay a one-time $60 deposit in order to secure my first appointment at CHV which will be applied to my first invoice. I understand that should I fail to show up for my appointment or need to reschedule and do not notify CHV of this at least one full business day prior to my appointment, my deposit will not be refunded and I will need to make another deposit if I wish to reschedule. Business Days are Monday-Friday, therefore a Monday 12 noon appointment cancellation or rescheduling for example must be communicated to CHV the prior Friday by 12 noon.

Yes, I Agree

Patient Information

Information about your pet(s)

Name of Pet 1

Birthdate or Approximate Age

Species

Dog

Cat

Other

Breed

Sex

Spayed Female

Intact Female

Neutered Male

Intact Male

Color

How Acquired

Rescue/Shelter Organization

Breeder

Found Stray

Pet Store

Family/Friend

Other

Does this pet have an insurance policy?

Yes

Name of Insurance Provider

What is covered (check all that apply)

Past Medical Issues (allergies, chronic conditions, behavioral, surgical procedures, etc.)

Current Medications or Prescription Diets (Dosage and Frequency)

Heartworm and Flea & Tick Prevention (Type and Approx. Last Dose)

Does this pet have medical records at another veterinarian?

Yes

Past Veterinary Clinic Info

How should we acquire past medical records?

I have access to the records and will email them to you at CHVteam@charlestonvets.com 24 hours+ prior to my first visit

I have hard copies of the records and will bring them to the clinic at least 1 business day before my visit

Please contact the past veterinarian on my behalf (may sometimes cause delays if clinic is unresponsive)

May we use your pet's name and image on social media and other marketing materials?

Yes

List any social media accounts for you or your pet you would like us to tag

Do you have an additional pet to add to your account?

Yes

Pet #2 Information

Name of Pet 2

Birthdate or Approximate Age

Species

Dog

Cat

Other

Breed

Sex

Spayed Female

Intact Female

Neutered Male

Intact Male

Color

How Acquired

Rescue/Shelter Organization

Breeder

Found Stray

Pet Store

Family/Friend

Other

Does this pet have an insurance policy?

Yes

Name of Insurance Provider

What is covered (check all that apply)

Past Medical Issues (allergies, chronic conditions, behavioral, surgical procedures, etc.)

Current Medications or Prescription Diets (Dosage and Frequency)

Heartworm and Flea & Tick Prevention (Type and Approx. Last Dose)

Does this pet have medical records at another veterinarian?

Yes

Past Veterinary Clinic Info

How should we acquire past medical records?

I have access to the records and will email them to you at CHVteam@charlestonvets.com 24 hours prior to my first visit

I have hard copies of the records and will bring them to the clinic at least 1 business day before my visit

Please contact the past veterinarian on my behalf (may sometimes cause delays if clinic is unresponsive)

May we use your pet's name and image on social media and other marketing materials?

Yes

List any social media accounts for you or your pet you would like us to tag

Do you have an additional pet to add to your account?

Yes

Pet #3 Information

Name of Pet 3

Birthdate or Approximate Age

Species

Dog

Cat

Other

Breed

Sex

Spayed Female

Intact Female

Neutered Male

Intact Male

Color

How Acquired

Rescue/Shelter Organization

Breeder

Found Stray

Pet Store

Family/Friend

Other

Does this pet have an insurance policy?

Yes

Name of Insurance Provider

What is covered (check all that apply)

Past Medical Issues (allergies, chronic conditions, behavioral, surgical procedures, etc.)

Current Medications or Prescription Diets (Dosage and Frequency)

Heartworm and Flea & Tick Prevention (Type and Approx. Last Dose)

Does this pet have medical records at another veterinarian?

Yes

Past Veterinary Clinic Info

How should we acquire past medical records?

I have access to the records and will email them to you at CHVteam@charlestonvets.com 24 hours prior to my first visit

I have hard copies of the records and will bring them to the clinic at least 1 business day before my visit

Please contact the past veterinarian on my behalf (may sometimes cause delays if clinic is unresponsive)

May we use your pet's name and image on social media and other marketing materials?

Yes

List any social media accounts for you or your pet you would like us to tag

Do you have an additional pet to add to your account?

Yes

Pet #4 Information

Name of Pet 4

Birthdate or Approximate Age

Species

Dog

Cat

Other

Breed

Color

Sex

Spayed Female

Intact Female

Neutered Male

Intact Male

How Acquired

Rescue/Shelter Organization

Breeder

Found Stray

Pet Store

Family/Friend

Other

Does this pet have an insurance policy?

Yes

Name of Insurance Provider

What is covered (check all that apply)

Past Medical Issues (allergies, chronic conditions, behavioral, surgical procedures, etc.)

Current Medications or Prescription Diets (Dosage and Frequency)

Heartworm and Flea & Tick Prevention (Type and Approx. Last Dose)

Does this pet have medical records at another veterinarian?

Yes

Past Veterinary Clinic Info

How should we acquire past medical records?

I have access to the records and will email them to you at CHVteam@charlestonvets.com 24 hours prior to my first visit

I have hard copies of the records and will bring them to the clinic at least 1 business day before my visit

Please contact the past veterinarian on my behalf (may sometimes cause delays if clinic is unresponsive)

May we use your pet's name and image on social media and other marketing materials?

Yes

List any social media accounts for you or your pet you would like us to tag