New Client Form

PRIMARY OWNER

Name*

First Last

Social Security #

Driver's License #*

Children (& ages)

Address*

Street Address City 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 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 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

info@lakeviewvet.com

(504) 482-2173

Fill out the form.

PRIMARY OWNER

CO-OWNER

Other Information

About Your Pet

Please fill in the following for each pet