Email

This field is for validation purposes and should be left unchanged.

Owner's Name:*

Prefix First Last

Co-Owner's Name:

Prefix First Last

Address*

Street Address Address Line 2 City State ZIP Code

Driver's License #*

Email Address*

Home Number

Work Number

Cell Number*

Co-Owner Work Number

Co-Owner Cell Number

Name of Previous Animal Hospital*

Write N/A if pet has never been to the vet.

Previous Animal Hospital Phone Number

Recommended by Whom?*

Place of Employment

May we have permission to use photos of your pet(s) on our website, Facebook page, and other social media outlets?*

Yes
No

I understand all prepaid deposits are nonrefundable.*

Yes

Rabies Vaccination Acknowledgement - In accordance with North Carolina law and for the safety of others, I acknowledge that my dog and/or cat must have a current rabies vaccination. If my pet has already been vaccinated, I agree to provide official documentation to Johnston Animal Hospital PRIOR to my pet's appointment, or authorize my previous veterinary provider to do so on my behalf. If I do not provide valid proof of current rabies vaccination before the appointment, I understand that: My pet will receive a rabies vaccine during the visit if the attending veterinarian determines it is medically safe to do so. I am responsible for any charges associated with the rabies vaccine. If the veterinarian determines it is not medically safe at that time, the rabies vaccine will be administered at a future visit when it becomes safe. I also understand that declining the rabies vaccine places me in violation of North Carolina law. In such cases, Johnston Animal Hospital reserves the right to refuse service, and my pet will not be seen.*

I understand and agree with the Rabies Vaccination Acknowledgement above

Rabies	Distemper	Distemp/Lepto	Flu	Bordetella	Lyme	Lepto

Rabies	Distemper	Distemp/Lepto	Flu	Bordetella	Lyme	Lepto

Rabies	Distemper	Distemp/Lepto	Flu	Bordetella	Lyme	Lepto

New Client Form

Step 1 of 3

First Pet

Second Pet

Third Pet

New Client Form

Step 1 of 3

First Pet

Second Pet

Third Pet

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