James Island Vet Hospital

756 Folly Road
Charleston, SC 29412

(843)795-5295

jamesislandvet.com

New Client Check In

Welcome to our new clients and patients! Please take a few moments to complete this form so that we may get to know you a little better.

Please note that this form is designed to register 2 pets. If you have additional pets, please alert the receptionist at the time of your appointment and they will be able to add all additional pets at that time. It also allows you to designate an alternate contact with the same legal permissions as yourself. If there are others, please ensure the front staff is aware. Last but not least, please bring a copy of your current driver's license or ID card at the time of your appointment.

Thank you for your cooperation in letting us assist you. We look forward to meeting you very soon.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Mailing Address (if different from above)
Street Address
City
,
State / Province
Zip / Postal Code
License Information
Please come prepared with your current driver's license or ID for our records.
Preferred Phone (required)
Phone TypePhone Number (required)
Secondary Phone
Phone TypePhone Number
Additional Phone
Phone TypePhone Number
E-Mail Address :
Contact Preferences (required)
(How may we contact you? Please select all that apply.)
Phone Call
E-mail
Text
Mail
Alternate Contact Waiver
The next section is for an alternate contact for your pet's records. This person may make appointments, authorize treatment, and receive information about my pet(s).
Alternate Contact Name
First Name
Last Name
Relationship :
Alternate Preferred Phone
Phone TypePhone Number
Alternate Second Phone
Phone TypePhone Number
Alternate Additional Phone
Phone TypePhone Number
How did you first learn of our veterinary practice? (required)

Medical records at another veterinary Practice? (required) :
May we request a transfer of records? :
Former Veterinary Practice(s) Name and Contact

Pet's Name: (required)

Type of Pet: (required) :
Breed: (required)

Age: Years/Months or DOB (required)

Sex (Select Male or Female) (required) :
Is your pet spayed or neutered? (required) :
Would you like us to call you for your appointment? (NON-Emergencies only please)
Reasons or conditions that prompted your visit?

Special requests or conditions? Please list any known allergies.

Additional Pet's Name:

Type of Pet: :
Breed:

Age: Years/Months or DOB

Sex (Select Male or Female) :
Is your pet spayed or neutered? :
Payment Policy
At your request, we will gladly discuss cost of services and/or prepare a written estimate for recommended procedures. Professional fees are due at the time services are rendered. Deposits are required for pets being admitted. For your convenience, we accept Visa, MasterCard, Discover, American Express, debit cards, cash and personal checks drawn from a local bank.
Selection (required)
(By selecting "I agree" and submitting this form, I acknowledge the Payment Policy set forth by James Island Veterinary Hospital.)
I agree
I do not agree

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