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.

Owner Information

Owner First Name *

Owner Last Name *

Owner Birth Date *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Alternate Phone

Address *

City *

State *

Zip Code *

Occupation *

Place of Employment *

Date of Birth *

Patient Information

Patient Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Describe in detail why your pet is being presented *

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?

Referral Information

Referring Hospital Name *

Referring Veterinarian Name *

How did you hear about us? *

Veterinarian

Friend / Family

Internet

Community Event

Signage

Printed Publication

Radio

Other

Spam Blocker

New Patient Form

OPTION 1Complete Online

OPTION 2Print & Complete

OPTION 3Complete on Arrival

New Patient Form

Owner Information

Patient Information

Payment & Insurance

Referral Information

Caring for Winston-Salem Pets

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival