New Client

Cane River Veterinary Wellness Clinic

660 West Main Street
Burnsville, NC 28714

(828)682-7710

www.canerivervet.com

NEW CLIENT CHECK-IN

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Name & Email (required)

First Name (required)	Last Name (required)

E-Mail Address :

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pet's vaccines current?

Do you have your pet's medical records?

Medical records at another veterinary practice?

Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No

Would you like us to call you for your appointment?

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

WE REQUIRE A $75 BOOKING FEE PER PET TO HOLD AN APPOINTMENT. FULL PAYMENT IS DUE AT THE TIME OF SERVICE. NEW CLIENTS WHO DO NOT SHOW UP FOR AN APPOINTMENT WILL NOT BE RESCHEDULED. WE CHARGE $75 FOR MISSED APPOINTMENTS AND SAME-DAY CANCELLATIONS.

I have read the above statement and agree that I understand. (required)

Yes, I agree

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Dr. Stacy Jones
660 West Main Street
Burnsville, NC 28714
(828)682-7710