Open 7 Days a Week - Including Saturday & Sunday

New Client Form - Dogs & Cats

Are you and your pet new to Carolina Veterinary Specialists in Huntersville? Please fill out our New Client Form for Dogs & Cats using one of the options below.

Please note that appointments must be made by phone, so please call us if you want to book an appointment.

OPTION 1
Fill Out Online

Complete the online form below and submit.

OPTION 2
Print & Complete

Once completed, bring the form with you.

Download Form

OPTION 3
Complete in Office

If you prefer, you can fill out the form when you arrive at our hospital.

IMPORTANT: If your pet is an avian or exotic patient, please complete the appropriate Species-Specific New Patient Questionnaire.

New Client Form - Dogs & Cats

Please provide us with the following information.

Thank you for trusting us with the veterinary care of your pet. So that we can become better acquainted and best serve your needs and expectations, please complete the following form. Email us any veterinarian records or documents to huntersvillereferrals@carolinavet.com.

CLIENT (OWNER) INFORMATION

Owner's Name *

Owner's date of birth (required for prescriptions) *

Street address *

City, state, ZIP *

Please check your PRIMARY contact method(s) below ↓

Phone (home)

Phone (cell)

Phone (work)

Email address *

Occupation

Place of employment

ADDITIONAL AUTHORIZED AGENT INFORMATION

Please list the name(s) and contact information of any other individuals over 18 years of age (eg. spouse), if any, that you wish to be listed as an Authorized Agent that can authorize urgent medical treatment changes and to whom we can release patient information if you are unavailable:

Name

Relationship

Phone

Email Address

Name

Relationship

Phone

Email Address

REFERRAL SOURCE OR REGULAR VETERINARIAN

If your pet has been examined by another veterinarian, please provide the following information:

Veterinarian’s name

Hospital name

Okay to contact for information?

Yes

How did you hear about us?

PET INFORMATION

Pet's name *

Species *

Breed

Color and/or markings

Pet’s date of birth *

Sex *

Rabies vaccine status (dogs, cats, and domestic ferrets only) *

Payment Policy

Payment in full is expected at the time services are provided or upon discharge of your pet if your pet is hospitalized. Initial payment of the emergency exam fee is due prior to treatment for all emergencies.

We will provide a written good-faith estimate of the cost of our services before extensive evaluation or treatment of your pet, or if your pet is hospitalized. However, unforeseen circumstances may arise that might influence your final bill. We will keep you updated daily regarding the amount due for hospitalized pets.

A deposit toward the cost of services is required for all emergencies and if your pet is hospitalized. In most instances, a deposit of 75% of the high end of the financial estimate is required for surgeries and other major procedures and for hospitalization services.

We accept payment by cash (we are not able to give change; amount must be exact), Visa, MasterCard, American Express, Discover, Care Credit, and Scratch Pay. We do not accept Apple pay or Google pay.

We appreciate your understanding of our financial policies. Please do not hesitate to speak with us if you have any questions or concerns regarding these policies or any other financial matters.

I hereby authorize and direct the veterinarian(s) at Carolina Veterinary Specialists to diagnose, administer or prescribe medications (recognizing that some medications used may be off-label), and perform therapeutic and/or surgical procedures that in their judgment are advisable for the well-being of my pet. I also understand that no warranty or guarantee has been made as to the result or a cure, and that I am financially responsible for the authorized services performed.

Signature *

Date *

Photo and Video Release Form

I, [Owner's Name], grant Carolina Veterinary Specialists, its representatives and employees the right to take photographs of me and/or my pet, [Pet's name], and to copyright, use and publish the same in print and/or electronically.

I agree that Carolina Veterinary Specialists may use such photographs of me and/or my pet with or without my pet’s name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, education, Web content, or social media.

Signature *

Date *

Emergency Intake Form

Date

Pet Name

If you are waiting to be seen, please fill out this form while waiting to be triaged by one of our veterinary technician/assistants. Be prepared that our wait times can vary with the wait time originally given. We are an emergency room, and we often see patients with severe, life-threatening conditions. We also see plenty of patients with urgent issues, but sometimes they have to wait if we are trying to save another pet’s life. If possible, make an appointment with your family vet for non-urgent care. Remember, if you are waiting for your pet to be seen, that is a good sign. If your pet is bumped to the front of the line that means they are very sick and need immediate care.

Please be kind and considerate to our staff. We are here to help you and your pets. That is our passion and what we have all dedicated our lives to, even with the pain and trauma that goes with it. We understand your fear and frustrations, but we will not tolerate people screaming, threatening, or abusing our staff. All of the medical world is overwhelmed and overworked right now, and that includes everyone in veterinary medicine. We are doing the best we can with what little resources and staff we have. If you cannot be patient and compassionate with us, we will not be able to help you or your pets.

Thank you for understanding. We appreciate everyone who offers us understanding and kindness while we work to help you and your family.

Pet’s primary care veterinary clinic

Please list your primary reason for visit today

When did you first notice the concern?

Has the concern improved, remained the same, or worsened since you first noticed it?

Have you had any diagnostic tests done elsewhere? If so, where?

Any previous injuries, illnesses or surgeries?

Any vomiting, diarrhea, coughing or sneezing?

Urinating and defecating ok? Normal consistency and amount?

Eating and drinking ok? Have you noticed any changes in their eating/drinking habits?

History of eating things they shouldn’t? Anything they could have gotten into?

Is their activity level normal?

What is their lifestyle like? (Indoor, outdoor, parks, beaches, hiking, grooming, boarding)?

Does your pet travel? If traveling, where to?

Flea/heartworm/tick prevention or supplements?

Up to date on vaccines?

Yes

List any prescription medications your pet is currently taking (please include frequency and dose given [i.e.: 1 tablet twice a day])

When were the medications last given [ie: last night at 6pm, this morning at 8am]?:

What does your pet eat? (food, treats, dental care, human food, etc.)

Any known allergies to food, medications, environmental, etc.? If so, explain:

Do we have permission for the following?

Emergency exam fee $195

Emergency treatment if your pet is in critical condition (IV catheter, IV fluids, pain medication, antibiotics, etc.) $600-800

Bloodwork (complete blood count, serum chemistry, electrolytes or blood gas analysis) $80-$300

X-rays (Chest or abdomen) $325-600

IV catheter placement and starting IV fluids $200-300

RABIES POLICY

North Carolina State Law requires every dog and cat of the age of four months and older to be vaccinated against Rabies. This law also applies to ferrets within the city limits of Charlotte. This vaccine must be administered by a licensed veterinarian.

Due to the nature of our business, for the protection of the client, the patient, and our staff, we must inform you of the North Carolina State Law regarding the Rabies vaccine.

If your pet bites you and/or an employee of Carolina Veterinary Specialists, we must inform Charlotte Mecklenburg County-Animal Care & Control immediately.

If your pet bites an employee and is unvaccinated, North Carolina State Law requires your pet to remain in our custody until they are contacted and authorize release. All costs associated with such custody are at the owner's expense.

If your pet bites an employee and is vaccinated, North Carolina State Law requires either the pet to be left in our custody, or be taken back to the owner’s primary residence until a quarantine period is determined by a local health director.
**By signing this policy, I acknowledge the statements listed above and fully understand North Carolina State Law regarding the Rabies vaccine.

Signature *

Date *

Pet's Name *

CPR Consent Form

Regardless of the nature of your pet’s emergency or condition, our hospital policy is to require the selection of a CPR code as a precautionary measure. CPR measures will be implemented if a crisis arises and you will be notified of your pet’s condition immediately after CPR commences.

CPR means “Cardiopulmonary Resuscitation” and is the treatment (resuscitation) of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.
DNR means “Do Not Resuscitate.” This means that if a pet stops breathing or his/her heart stops, no effort will be made to attempt to revive the pet, and the pet will pass away.

Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, intubation, ventilator support, emergency medications, or other heroic interventions, I request that the doctor(s) at Carolina Veterinary Specialists conduct OR not conduct such medical care as indicated below.

If I (owner or representative of owner) request such emergency procedures, I agree to be held responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to the CPR fees in addition to other fees already identified by the practice and agreed upon by me.

There will be a CPR fee of $300-500. A further plan after successful resuscitation will be discussed.

Please select one of the CPR options. Regardless of your choice, you will be notified immediately. *

I ELECT CPR efforts - Compressions, intubation, ventilation, emergency medications.

I DECLINE CPR efforts - No heroic measures to be taken – “DNR” status.

The above is a preliminary decision so that our staff knows how to best proceed with the care of your pet. You may elect at any time, after speaking with the doctor or as events progress, to change the CPR status of your pet. Please let us know as soon as possible if you would like to change your pet’s CPR status.

I accept that if the hospital staff is unable to reach me within 20 minutes after the initial CPR procedures and, after exercising reasonable judgment, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the doctors and staff at this facility, even the most successful CPR that may restore my pet’s life may not allow for my pet to regain his/her normal mental and physical health and, thus, may leave him/her as an invalid.

Signature of Owner or Authorized Agent *

Date *

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Patients

Patient Information
New Client Form - Dogs & Cats
Avian (Bird) Patient Form
Exotic Mammal Patient Form
Reptile Patient Form
Emergency Intake Form - Dogs & Cats
Pay Online
Financing Options
Blog

Happy Tails from Clients

"Great place to take your animals. They care and support your every needs. Can't ask for a better place."
- Clint E.

New Client Form - Dogs & Cats

OPTION 1Fill Out Online

OPTION 2Print & Complete

OPTION 3Complete in Office

IMPORTANT: If your pet is an avian or exotic patient, please complete the appropriate Species-Specific New Patient Questionnaire.

New Client Form - Dogs & Cats

CLIENT (OWNER) INFORMATION

Please check your PRIMARY contact method(s) below ↓

ADDITIONAL AUTHORIZED AGENT INFORMATION

REFERRAL SOURCE OR REGULAR VETERINARIAN

PET INFORMATION

Payment Policy

Photo and Video Release Form

Emergency Intake Form

RABIES POLICY

CPR Consent Form

Caring for Pets in Huntersville

OPTION 1
Fill Out Online

OPTION 2
Print & Complete

OPTION 3
Complete in Office