New Client Form The following form will help us meet the needs of you and your pet. We look forward to meeting you both very soon! ΔClient InformationInformation about youFirst Name Last Name Email Mobile Phone Other Phone AddressAddress Line 1 Address Line 2 City State Zip Code Are there other individuals authorized to make medical decisions for your pet(s)? Yes NoFirst Name Last Name Email Mobile Phone Relation First Name Last Name Email 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 careIs there anything else we should know that will help us serve you best? How did you find out about Charleston Harbor Veterinarians? Do you have a preferred doctor and/or team member? Patient InformationInformation about your pet(s)Name of Pet 1 Birthdate or Approximate Age Species Dog Cat OtherBreed Sex Spayed Female Intact Female Neutered Male Intact MaleColor How Acquired Rescue/Shelter Organization Breeder Found Stray Pet Store Family/Friend OtherDoes this pet have an insurance policy? Yes NoName of Insurance Provider What is covered (check all that apply) AccidentIllnessWellness/Preventative CarePrescription MedicationPrescription Food/SupplementsHereditary/Congenital ConditionsChronic ConditionsPast 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 NoPast 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 I will personally bring copies of the records to my first visit Please contact the past veterinarian on my behalf (may sometimes cause delays)Does this pet have social media and can we use their name and images on our accounts? Do you have an additional pet to add to your account? Yes NoPet #2 InformationName of Pet 2 Birthdate or Approximate Age Species Dog Cat OtherBreed Sex Spayed Female Intact Female Neutered Male Intact MaleColor How Acquired Rescue/Shelter Organization Breeder Found Stray Pet Store Family/Friend OtherDoes this pet have an insurance policy? Yes NoName of Insurance Provider What is covered (check all that apply) AccidentIllnessWellness/Preventative CarePrescription MedicationPrescription Food/SupplementsHereditary/Congenital ConditionsChronic ConditionsPast 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 NoPast 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 I will personally bring copies of the records to my first visit Please contact the past veterinarian on my behalf (may sometimes cause delays)Does this pet have social media and can we use their name and images on our accounts? Do you have an additional pet to add to your account? Yes NoPet #3 InformationName of Pet 3 Birthdate or Approximate Age Species Dog Cat OtherBreed Sex Spayed Female Intact Female Neutered Male Intact MaleColor How Acquired Rescue/Shelter Organization Breeder Found Stray Pet Store Family/Friend OtherDoes this pet have an insurance policy? Yes NoName of Insurance Provider What is covered (check all that apply) AccidentIllnessWellness/Preventative CarePrescription MedicationPrescription Food/SupplementsHereditary/Congenital ConditionsChronic ConditionsPast 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 NoPast 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 I will personally bring copies of the records to my first visit Please contact the past veterinarian on my behalf (may sometimes cause delays)Does this pet have social media and can we use their name and images on our accounts? Do you have an additional pet to add to your account? Yes NoPet #4 InformationName of Pet 4 Birthdate or Approximate Age Species Dog Cat OtherBreed Color Sex Spayed Female Intact Female Neutered Male Intact MaleHow Acquired Rescue/Shelter Organization Breeder Found Stray Pet Store Family/Friend OtherDoes this pet have an insurance policy? Yes NoName of Insurance Provider What is covered (check all that apply) AccidentIllnessWellness/Preventative CarePrescription MedicationPrescription Food/SupplementsHereditary/Congenital ConditionsChronic ConditionsPast 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 NoPast 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 I will personally bring copies of the records to my first visit Please contact the past veterinarian on my behalf (may sometimes cause delays)Does this pet have social media and can we use their name and images on our accounts? Submit Form