New Client Registration

*Please note, a $40 deposit is required for all new client appointments that will go towards the appointment fee. The deposit will be forfeited for all no shows or if the appointment is not canceled with at least a 24 hour notice. If you are more than one hour late for your appointment, you will need to reschedule. Thank you for understanding!

Your Name*

First NameLast Name

Spouse/ Significant Other

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Email Address*

example@example.com

Primary Contact Phone Number*

Area CodePhone Number

Secondary Contact Phone Number*

Area CodePhone Number

Your Employer's Name & Phone Number*

Spouse's Employer's Name & Phone Number

Who may we contact in case of an emergency if you are unavailable?*

First NameLast Name

Emergency Contact's Phone Number*

Area CodePhone Number

Emergency Contact's relationship to you*

Friend, Parent, sibling, etc.

Pet's Name*

Pet's Species*

ex. dog, cat, bird, etc.

Pet's Breed*

ex. "Yorkie"

Pet's Age/ Birthdate*

Pet's Color*

Pet's Weight*

Pet's Sex*

Is your pet spayed or neutered?*

Is your pet microchipped?*

Has your pet ever shown signs of aggression?*

If your pet is coming to us from another veterinarian, may we collect previous records?*

May we release your pet's LVCC medical records to your primary or referring DVM?*

Previous veterinary care by*

Doctor or practice name

Please Note: We only send records out of our practice by your direct request following each visit. Without this, we do not send records to your previous or primary veterinarian automatically. Please be aware that we now offer formal estimates or treatment plans for all services by request. Please ask our staff if you would like to be provided a treatment plan outlining the cost of your pet's care at any time. A deposit may be required for surgery or hospitalization upon admittance. Full payment is due upon the conclusion of care for each individual patient and out-patient services. No-show appointments will be charged $40.

Please type your initials to acknowledge that you have read and agree to the above policy.*

Method of Payment*

How do you prefer to receive reminders and health updates from us?*

Do you give LVCC permission to use your pet's pictures for social media/Facebook page.*

How did you become familiar with our practice?*

If you were referred to us by another practice or individual, please let us know their name.*

If no specific referral, please type "NA."

DateTime

Signature*

Please verify that you are human*