Please use the form below to pre-register you and your pet for care at Charleston Veterinary Referral Center. You may use this form prior to a visit with one of our specialsits, or to pre-register to streamline the process should your pet have an emergency and come to CVRC. If your pet is currently having an emergency, or might be having an emergency, please contact us at (843) 614-8387. Contact Information Your Name * Spouse/Partner Name Email address * Address Country United States Address 1 Address 2 City State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP Code Home Phone # * Mobile Phone # Spouse Phone # Fax # Employer Occupation Emergency Contact Information Emergency Contact Name If we are unable to reach you, who may we contact in case of emergency? Emergency Contact Phone Do you authorize your emergency contact to make treatment decisions if you are not reachable? * Yes No Pet Information Name * Species * Canine Feline Other Breed * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Color * Sex * - Select -FemaleFemale, SpayedMaleMale, NeuteredOther/Unknown Presenting Problem / Relevant History / Special Needs / Concerns Primary Veterinarian Information Primary Veterinarian Hospital Phone # (if known) City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Additional Information Should we contact you to schedule an appointment? * Yes No How did you hear about us? * - Select -AdvertisementDrove byInternet searchReferred by my veterinarianReferred by friendOther How would you like to be contacted? Home Phone Mobile Phone Email Are you a member of the US Military, Police or Firefighter? No Yes Upload Records or Images Upload Records/Images Upload Records/Images Upload Records/Images Upload Records/Images Math question * 1 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.