New Patient Form

Is your pet a new patient at Carolina Veterinary Specialists in Winston-Salem? Please complete our New Patient Form using one of the following options.

OPTION 1
Complete Online

Fill in and send the form below.

OPTION 2
Print & Complete

Bring the completed form to your appointment with you.

Download Form

OPTION 3
Complete on Arrival

If you'd like, you can complete the form when you arrive at our hospital.

New Patient Form

Please provide us with the following information.

Have you or your pet been seen by us before? *

Yes

No, this is our first time here

Reason for your pets visit/Presenting problem *

Owner Information

Owner First Name *

Owner Last Name *

Address *

City *

State *

Zip Code *

Primary Phone *

Alternate Phone *

Email *

Owner Birth Date *

Secondary Owner / Authorized Agent Name

Phone

Patient Information

Patient Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Gender *

Spayed or Neutered? *

Vaccination Status *

Date of Last Rabies Vaccine

Payment & Insurance

PAYMENT IN FULL IS EXPECTED AT THE TIME SERVICES ARE RENDERED. Prior to the treatment of your pet we will provide you with an itemized estimate. It is the policy of Carolina Veterinary Specialists to require a deposit on all hospitalized patients and those outpatients having extensive diagnostic or treatment procedures. Please ask our client care team if you have any questions.

Do you carry pet insurance? *

If yes, what is the name of your insurance company?

Policy Number

Primary Veterinarian Information

Primary Veterinary Hospital Name *

Primary Veterinarian Name *

Spam Blocker

New Patient Form

OPTION 1Complete Online

OPTION 2Print & Complete

OPTION 3Complete on Arrival

New Patient Form

Owner Information

Patient Information

Payment & Insurance

Primary Veterinarian Information

Caring for Winston-Salem Pets

Alternate Emergency Centers:

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival