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40I South Sharon Amity Rd.,Suite A,
Charlotte, NC 28211

(704) 365-3787

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Home
Services
About
Client Center
Contact
- Emergency Services
- Prescription Refill

New Client Registration Form

"*" indicates required fields

Welcome

Thank you for the opportunity to care for your pet(s). We'll be happy to answer any questions you have about your pet's health. To insure the best care possible, please take the time to fill in this form completely. Thank you!

Owner's Name:*

First Last

Address:

Street Address Address Line 2 City State ZIP Code

Email:*

Phone:*

Home

Mobile

Work

Please supply at least one phone number

Would you like to add a Spouse/Co-Owner?

Yes

No

Spouse/Co-Owner Name:

Spouse/Co-Owner Phone:

Spouse/Co-Owner Email:

How did you hear about us?*

Drive By

Website

Internet/Social Media

Friend/Family

Other

If " Friend/Family" above, please let us know whom we can thank.

If " Other" above, please explain.

Pet Information

Previous Veterinarian Practice Name:

City/State:

Pet's Name:*

Species/Sex:*

Canine Male

Canine Female

Feline Male

Feline Female

Spayed/Neutered:*

Yes

No

Age/Date of Birth:*

Breed:*

Color:*

Would you like to add another pet?*

Yes

No

Pet 2's Name:

Pet 2's Species/Sex:

Canine Male

Canine Female

Feline Male

Feline Female

Pet 2 Spayed/Neutered:

Yes

No

Pet 2's Age/Date of Birth:

Pet 2's Breed:

Pet 2's Color:

Would you like to add a 3rd Pet?*

Yes

No

Pet 3's Name:

Pet 3's Species/Sex:

Canine Male

Canine Female

Feline Male

Feline Female

Pet 3 Spayed/Neutered:

Yes

No

Pet 3's Age/Date of Birth:

Pet 3's Breed:

Pet 3's Color:

Media Release

I grant permission to Cotswold Animal Hospital to use images/video/reviews of: myself and my pet(s) on all Social Media platforms accosiated with Cotswold Animal Hospital. I waive my right to inspect or approve the finished photograph or electronic matter. I waive the right to royalties and other compensation arising from or related to the use of the image. I waive my right to legal representation for all claims and liability relating to said images/videos .*

Yes

No

Authorization

I am verifying that I am the owner or the authorized agent of the animal(s) described above, and I am above the age of 18. I, hereby authorize Cotswold Animal Hospital, by its veterinarians, technicians, assistants and employees of Cotswold Animal Hospital to perform the services, treatments, and prescribe necessary medication for the above animals. I am assuming all financial responsibility for these pets.*

I authorize and accept.

Signature*

Accepted Methods of Payment: Cash, Debit, Credit Card and CareCredit
We Do Not Accept Personal Checks

Date:*

Month

Day

Year

CAPTCHA

Email

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

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Cotswold Animal Hospital

401 South Sharon Amity Rd. Suite A
Charlotte, NC 28211

Phone: (704) 365-3787

Hospital Hours:
Monday - Friday: 7:30am - 6:00pm
Weekend: Closed

Veterinarians serving Cotswold, Charlotte and the surrounding areas.

https://cotswoldanimalhospital.com/

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