New Client Form

Name: Carolina Ranch Animal Hospital & Resort
Telephone: 919-662-3200
Price range: $$
Rating: 4.9

How did you hear about the Ranch?*
Your current veterinary hospital*
Please indicate the name and location of the veterinary hospital your pet(s) last visited.
Owner Name*
First Last
Do you have another name you wish to associate with your account?
- Yes
- No
Other Names Associated with this Account
First Last
List any other names (spouse/partner/relative) you wish to include on your account.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*

Please provide your email address (not your home address). Email is the primary means of reminders (vaccines, appointments, etc.) used by Carolina Ranch.
Your Phone Number*
This is the phone number we would most likely be able to reach you.
My Primary Phone is:*
- Home Phone
- Cell Phone
- Work Phone
Do You Have A Phone Number for Your Additional Contact?*
- Yes
- No
Please indicate if you have an additional phone number you wish to provide.
Additional Phone Number
Please list any additional phone numbers.
PET INFORMATION

Please tell us about your pet(s).
Name of Pet*
Breed
If your pet is a "mixed" breed, give us the closest estimation of the breed (Lab/Chow, Boxer/Pit, Dachshund/Chihuahua, etc.).
Your Pet's Birthdate
MM slash DD slash YYYY

If you know your pet's birthdate, please enter it below. If you don't know your pet's birthdate, give us the closest approximate age on the next line.
Your Pet's Age (in years/months or weeks)
Enter your pets approximate age in years/months if you do not know your pet's birthdate.
Your Pet's Color
Please enter your pet's color & any markings that distinguish the coat.
Pet's Sex*
- Male (not neutered)
- Female (not spayed)
- Neutered Male
- Spayed Female
- Unknown
Please indicate the sex of your pet. If your pet is "unaltered" please make sure to let us know.
Does your pet have a Microchip?
- Yes
- No
A microchip is a tiny transmitter containing identifying information that is implanted under the skin of your pet.
What is the microchip number?
Please list the unique identifier number associated with your pet's microchip.
Has your pet had any previous serious illnesses or surgeries?
- Yes
- No
- I'm not sure
Has your pet had any previous serious illnesses or surgeries?
Give details regarding any past or recurring illnesses you have experienced with your pet. Also list any surgeries your pet has had.
Does your pet have any allergies (food or medication)?
- Yes
- No
Please indicate whether or not your pet has any allergies.
Allergies
If your pet has any allergies to vaccines or medications, please list any you are aware of.
Is your pet currently on any special diets or medications?
- Yes
- No
This includes food prescribed by a veterinarian or food used to prevent allergic reactions. Medications may include both prescribed and over-the-counter medications.
Special Diet/Medications
Please list any special foods or medications your pet requires.
Does your pet have any special conditions or requirements we should be aware of?
- Yes
- No
This could be any physical limitations, such as leash placement, temperament issues or behavioral issues.
Please check any that apply:
- Joint pain
- Fast eater
- Chronic conditions (skin, ears or bowels)
- Will climb
- May destroy bedding
- Possible bathing anxiety
- Thunderstorm anxiety
- Laryngeal Paralysis/Collapsing Trachea
- Possible dog aggression
- Possible human aggression
Would you like to add a second pet?*
- Yes
- No
PET #2 INFORMATION

Please tell us about your second pet.
Name of Pet*
Breed
If your pet is a "mixed" breed, give us the closest estimation of the breed (Lab/Chow, Boxer/Pit, Dachshund/Chihuahua, etc.).
Your Pet's Birthdate
MM slash DD slash YYYY

If you know your pet's birthdate, please enter it below. If you don't know your pet's birthdate, give us the closest approximate age on the next line.
Your Pet's Age (in years/months or weeks)
Enter your pets approximate age in years/months if you do not know your pet's birthdate.
Your Pet's Color
Please enter your pet's color & any markings that distinguish the coat.
Pet's Sex*
- Male (not neutered)
- Female (not spayed)
- Neutered Male
- Spayed Female
- Unknown
Please indicate the sex of your pet. If your pet is "unaltered" please make sure to let us know.
Does your pet have a Microchip?
- Yes
- No
A microchip is a tiny transmitter containing identifying information that is implanted under the skin of your pet.
What is the microchip number?
Please list the unique identifier number associated with your pet's microchip.
Has your pet had any previous serious illnesses or surgeries?
- Yes
- No
- I'm not sure
Has your pet had any previous serious illnesses or surgeries?
Give details regarding any past or recurring illnesses you have experienced with your pet. Also list any surgeries your pet has had.
Does your pet have any allergies (food or medication)?
- Yes
- No
Please indicate whether or not your pet has any allergies.
Allergies
If your pet has any allergies to vaccines or medications, please list any you are aware of.
Is your pet currently on any special diets or medications?
- Yes
- No
This includes food prescribed by a veterinarian or food used to prevent allergic reactions. Medications may include both prescribed and over-the-counter medications.
Special Diet/Medications
Please list any special foods or medications your pet requires.
Does your pet have any special conditions or requirements we should be aware of?
- Yes
- No
This could be any physical limitations, such as leash placement, temperament issues or behavioral issues.
Please check any that apply:
- Joint pain
- Fast eater
- Chronic conditions (skin, ears or bowels)
- Will climb
- May destroy bedding
- Possible bathing anxiety
- Thunderstorm anxiety
- Laryngeal Paralysis/Collapsing Trachea
- Possible dog aggression
- Possible human aggression
Would you like to add a third pet?*
- Yes
- No
PET #3 INFORMATION

Please tell us about your third pet.
Name of Pet*
Breed
If your pet is a "mixed" breed, give us the closest estimation of the breed (Lab/Chow, Boxer/Pit, Dachshund/Chihuahua, etc.).
Your Pet's Birthdate
MM slash DD slash YYYY

If you know your pet's birthdate, please enter it below. If you don't know your pet's birthdate, give us the closest approximate age on the next line.
Your Pet's Age (in years/months or weeks)
Enter your pets approximate age in years/months if you do not know your pet's birthdate.
Your Pet's Color
Please enter your pet's color & any markings that distinguish the coat.
Pet's Sex*
- Male (not neutered)
- Female (not spayed)
- Neutered Male
- Spayed Female
- Unknown
Please indicate the sex of your pet. If your pet is "unaltered" please make sure to let us know.
Does your pet have a Microchip?
- Yes
- No
A microchip is a tiny transmitter containing identifying information that is implanted under the skin of your pet.
What is the microchip number?
Please list the unique identifier number associated with your pet's microchip.
Has your pet had any previous serious illnesses or surgeries?
- Yes
- No
- I'm not sure
Has your pet had any previous serious illnesses or surgeries?
Give details regarding any past or recurring illnesses you have experienced with your pet. Also list any surgeries your pet has had.
Does your pet have any allergies (food or medication)?
- Yes
- No
Please indicate whether or not your pet has any allergies.
Allergies
If your pet has any allergies to vaccines or medications, please list any you are aware of.
Is your pet currently on any special diets or medications?
- Yes
- No
This includes food prescribed by a veterinarian or food used to prevent allergic reactions. Medications may include both prescribed and over-the-counter medications.
Special Diet/Medications
Please list any special foods or medications your pet requires.
Does your pet have any special conditions or requirements we should be aware of?
- Yes
- No
This could be any physical limitations, such as leash placement, temperament issues or behavioral issues.
Please check any that apply:
- Joint pain
- Fast eater
- Chronic conditions (skin, ears or bowels)
- Will climb
- May destroy bedding
- Possible bathing anxiety
- Thunderstorm anxiety
- Laryngeal Paralysis/Collapsing Trachea
- Possible dog aggression
- Possible human aggression
Would you like to add a fourth pet?*
- Yes
- No
PET #4 INFORMATION

Please tell us about your fourth pet.
Name of Pet*
Breed
If your pet is a "mixed" breed, give us the closest estimation of the breed (Lab/Chow, Boxer/Pit, Dachshund/Chihuahua, etc.).
Your Pet's Birthdate
MM slash DD slash YYYY

If you know your pet's birthdate, please enter it below. If you don't know your pet's birthdate, give us the closest approximate age on the next line.
Your Pet's Age (in years/months or weeks)
Enter your pets approximate age in years/months if you do not know your pet's birthdate.
Your Pet's Color
Please enter your pet's color & any markings that distinguish the coat.
Pet's Sex*
- Male (not neutered)
- Female (not spayed)
- Neutered Male
- Spayed Female
- Unknown
Please indicate the sex of your pet. If your pet is "unaltered" please make sure to let us know.
Does your pet have a Microchip?
- Yes
- No
A microchip is a tiny transmitter containing identifying information that is implanted under the skin of your pet.
What is the microchip number?
Please list the unique identifier number associated with your pet's microchip.
Has your pet had any previous serious illnesses or surgeries?
- Yes
- No
- I'm not sure
Has your pet had any previous serious illnesses or surgeries?
Give details regarding any past or recurring illnesses you have experienced with your pet. Also list any surgeries your pet has had.
Does your pet have any allergies (food or medication)?
- Yes
- No
Please indicate whether or not your pet has any allergies.
Allergies
If your pet has any allergies to vaccines or medications, please list any you are aware of.
Is your pet currently on any special diets or medications?
- Yes
- No
This includes food prescribed by a veterinarian or food used to prevent allergic reactions. Medications may include both prescribed and over-the-counter medications.
Special Diet/Medications
Please list any special foods or medications your pet requires.
Does your pet have any special conditions or requirements we should be aware of?
- Yes
- No
This could be any physical limitations, such as leash placement, temperament issues or behavioral issues.
Please check any that apply:
- Joint pain
- Fast eater
- Chronic conditions (skin, ears or bowels)
- Will climb
- May destroy bedding
- Possible bathing anxiety
- Thunderstorm anxiety
- Laryngeal Paralysis/Collapsing Trachea
- Possible dog aggression
- Possible human aggression
Would you like to add a fifth pet?*
- Yes
- No
PET #5 INFORMATION

Please tell us about your fifth pet.
Name of Pet*
Breed
If your pet is a "mixed" breed, give us the closest estimation of the breed (Lab/Chow, Boxer/Pit, Dachshund/Chihuahua, etc.).
Your Pet's Birthdate
MM slash DD slash YYYY

If you know your pet's birthdate, please enter it below. If you don't know your pet's birthdate, give us the closest approximate age on the next line.
Your Pet's Age (in years/months or weeks)
Enter your pets approximate age in years/months if you do not know your pet's birthdate.
Your Pet's Color
Please enter your pet's color & any markings that distinguish the coat.
Pet's Sex*
- Male (not neutered)
- Female (not spayed)
- Neutered Male
- Spayed Female
- Unknown
Please indicate the sex of your pet. If your pet is "unaltered" please make sure to let us know.
Does your pet have a Microchip?
- Yes
- No
A microchip is a tiny transmitter containing identifying information that is implanted under the skin of your pet.
What is the microchip number?
Please list the unique identifier number associated with your pet's microchip.
Has your pet had any previous serious illnesses or surgeries?
- Yes
- No
- I'm not sure
Has your pet had any previous serious illnesses or surgeries?
Give details regarding any past or recurring illnesses you have experienced with your pet. Also list any surgeries your pet has had.
Does your pet have any allergies (food or medication)?
- Yes
- No
Please indicate whether or not your pet has any allergies.
Allergies
If your pet has any allergies to vaccines or medications, please list any you are aware of.
Is your pet currently on any special diets or medications?
- Yes
- No
This includes food prescribed by a veterinarian or food used to prevent allergic reactions. Medications may include both prescribed and over-the-counter medications.
Special Diet/Medications
Please list any special foods or medications your pet requires.
Does your pet have any special conditions or requirements we should be aware of?
- Yes
- No
This could be any physical limitations, such as leash placement, temperament issues or behavioral issues.
Please check any that apply:
- Joint pain
- Fast eater
- Chronic conditions (skin, ears or bowels)
- Will climb
- May destroy bedding
- Possible bathing anxiety
- Thunderstorm anxiety
- Laryngeal Paralysis/Collapsing Trachea
- Possible dog aggression
- Possible human aggression

New Client Form

PET INFORMATION

PET #2 INFORMATION

PET #3 INFORMATION

PET #4 INFORMATION

PET #5 INFORMATION

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