Hutto Veterinary Clinic - Holly Hill, SC

Countryside Companion Veterinary Services

7659 Old State Road,
Holly Hill, SC 29059

(803)496-5037

www.huttoveterinaryclinic.com

New Client Form

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

How did you hear about us? (required)
Facebook
Google Search
Friend or Family
Other

If other, please explain.

Your Full Name (required)

First Name (required)	Last Name (required)

Address (Street Number & Name) *(required)*
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Preferred Phone Number (required)
Phone Type	Phone Number (required)

Secondary Phone Number
Phone Type	Phone Number

E-Mail Address :

I would like to receive reminders by... (required)

Text
Email
Phone Call
Postal Mail

Where can we call for previous records?

Pet's Name (required)

Pet's Breed

Color (required)

Date of Birth or Estimated Age (including weeks, months or years) (required)

Sex (required)

Male
Female
Unknown

Neutered/Spayed (required)

Neutered
Spayed
Intact
Unknown

We require proof of current Rabies vaccine or will administer the vaccine at your visit. We also offer additional vaccines we can discuss with you. Does your pet need vaccines updated? (required)

Yes
No
Unsure

Please list any medications, supplements, heartworm, flea or tick prevention your pet receives. Type "none" if no medication given. (required)

Why are we seeing your pet today? (required)

Pet #2 - Pet's Name

Pet #2 - Pet's Breed

Pet #2 - Color

Pet #2 - Date of Birth or Estimated Age (including weeks, months or years)

Pet #2 - Sex

Male
Female
Unknown

Pet #2 - Neutered/Spayed

Neutered
Spayed
Intact
Unknown

Pet #2 - We require proof of current Rabies vaccine or will administer the vaccine at your visit. We also offer additional vaccines we can discuss with you. Does your pet need vaccines updated?

Yes
No

Pet #2 - Please list any medications, supplements, heartworm, flea or tick prevention your pet receives. Type "none" if no medication given.

Pet #2 - Why are we seeing your pet today?

If you have additional pets to add to your account, please email it to us or bring the information with you when you come for your visit.

I authorize Hutto Veterinary Clinic to photograph my pet(s) and use photos on social media networks, in our clinic, in marketing materials and on our website. *This release will remain in effect until you notify us in writing of any desired changes.* (required) :

We will gladly prepare a written estimate upon request at any time. All fees are due at the time services are rendered. We accept all major credit cards, cash, and checks. There will be a $35 service charge for any returned checks. Do you agree? (required) :

I hereby agree that all of the above information is correct to the best of my knowledge and I assume responsibility for the animal(s) listed. (required) :

Today's Date: (required) :

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