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! If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Your Name * Address * City * Zip / Post Code * Email * Secondary Email Cell Phone * Secondary Phone Preferred Method of Contact * EmailPhoneText Other Authorized Persons to Make Medical Decisions for Pet (Name, Relationship, Phone/Email Contact) What is Your Least Favorite Part of a Veterinary Visit? How Much Do You Want to be Involved in Your Pet's Visit? I want to know all and see allI'd like the veterinary team to provide detailed explanations but don't wish to see everythingI'd like to see what's going on but give me the bullet points Anything Else we Should Know About You? Name of Pet (please use additional forms for other pets) * Birthdate Species * DogCatOther Breed Sex * Spayed FemaleNeutered MaleIntact FemaleIntact Male Color How Acquired BreederFriend/FamilyPet StoreShelterStrayOther Past Medical Issues (Ears, Skin, Surgery, Cancer, Infections, etc.) Current Medications, Dose and Frequency Heartworm Prevention Type and Flea/Tick Prevention (approx. date of last dose) Current Food, Daily Amount Past Veterinarian and Medical Records - If you have access to or are able to obtain medical records from your past veterinarian(s), please share an image or pdf copy by email (CHVteam@charlestonvets.com) or text (843-410-8290) as early as possible prior to your visit. If you don't have the records or would like us to request them for you, please provide the veterinarian's name and phone number. Is There Someone We Can Thank for Referring You? If not, how did you hear about us? May we use your pet's name and pictures on social media? YesNo