Thomasville & Kernersville, N.C. Vet Practice


New Southwoods Clients: If you are a new client please call for an appointment. Our office number is 336.275.7266 For your convenience, we have provided a form to fill out and submit to us prior to your first appointment. Please fill out 1 form per new patient.
Owner Information:
	* indicates required field
* Name:
E-mail Address:
* Address:

* City:
* State:
ZIP Code:
* Home Telephone:
Work Telephone:
* Cell (Other):

Pet Information:
* Pet's Name:
* Species (dog, cat, etc.):
* Breed:
* Color:
Age:
Birthdate:
Sex:		Male Female
* Spayed/neutered:		Yes No
* Vaccinations up to date?		Yes No
If yes, previous Animal Hospital:
* Known allergies:
Pet Origin:

How did you find our site?		Phone Book
		Drove By
		Website
		Friend/Relative
		Other
Reason for Visit/Comments:

All payments are expected at the time that services are rendered.
Please enter your preferred method of payment:		Cash Check
		Mastercard Visa Care Credit
If paying by check, please enter Drivers License Number:
Hopital/Treatment/Fees: Payment is expected at the time services are rendered. I understand that an estimate of the costs for veterinary services will be provided to me at my request and that I am encouraged to discuss all fees attendant to such care before services are rendered and during my pet's ongoing medical treatment. If my pet is hopitalized, I will assume financial responsibility for the balance of all services rendered on a cash, credit card or check basis at the time my pet is discharged from the hospital. In the event my pet is hospitalized for more than 48 hours and my attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every 48 hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day. Signature: (To be filled out upon your visit) Date: (To be filled out upon your visit)

Owner Information:

Pet Information:

All payments are expected at the time that services are rendered.