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New Client Form
Fill out the form.
PRIMARY OWNER
Name
*
First
Last
Social Security #
Driver's License #
*
Children (& ages)
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
Email
Place of employment
If necessary, may we contact you at work?
Yes
No
Job Title
Employer's Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Work Phone
CO-OWNER
Do you wish to specify a co-owner?
Yes
No
Name
First
Last
Co-owner
Spouse
Does this person have permission to make decisions concerning your pets?
Yes
No
Home Phone
Cell Phone
Work Phone
Place of employment
Job Title
Employer's Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If necessary, may we contact co-owner/spouse at work?
Yes
No
Other Information
How did you become aware of our hospital?
Personal Recommendation
Internet
Hospital Sign
Whom may we thank?
Please specify
Google
Yelp
All fees are due at the time services are rendered. We accept Visa, Mastercard, Discover, American Express and CareCredit credit cards as well as cash, personal checks, and debit cards. Any balances carried by Lakeview Veterinary Hospital, Inc. will be charged a monthly service charge on all accounts over 30 days and a statement fee of $6.00.
To prevent the spread of infectious disease and parasites, all in-patients, out-patients, boarders and grooming pets must be current on all vaccines and be free of parasites. I understand this to be a strict of the clinic and authorize the doctors to provide my pet or pets with vaccinations and pest control as needed.
I give permission for Lakeview Veterinary to use photos of pets on our website or social media.
Your Signature (please enter your full name)
Date
About Your Pet
So that we are able to suit your individual needs - which do you feel most applies to you?
Choose One
I feel that my pet is another member of my family.
I feel that my pet is just a pet.
Choose One
I want the best medical care available for my pet. Please recommend anything that you feel is necessary for good health.
I want good medical care for my pet, but there is a limit to what I am able to have done. I want you to perform only the services that I request.
Choose One
I want to learn as much as I can about pet health care. Please explain in detail what has been done for my pet or what is needed.
I would prefer you just summarize what has been done for my pet or what is needed.
I want my pet healthy, but don't need to know what has been done.
Choose One
I prefer to be present when my pet is examined and treated.
I would rather not see my pet examined and treated.
What prior illness or surgery should we know about?
Is your pet currently on a special diet or medication? (Please explain)
Please fill in the following for each pet
Name
Species
Breed
Description
Date of birth
Sex
Altered
Dates Vaccinated
Microchip