New Patient Form (Exisiting Client)

Welcome to the Lifetime Family!

New Patient Information
Client Name (as existing in Lifetime's records)

First Name Last Name
Owner's Date of Birth (*REQUIRED per DEA regulations for certain medications given to patients)

Month Day Year
Date
Pet Information
Pet Name
Species
If other, please specify species:
Breed
DOB/Age
Color
Sex
Vaccine History

Please indicate the date your pet last received the following recommended vaccines:
Cats
FVRCP

Month Day Year
Date
Leukemia

Month Day Year
Date
Rabies

Month Day Year
Date
Dogs
DAPP

Month Day Year
Date
Leptospirosis

Month Day Year
Date
Bordetella

Month Day Year
Date
Rabies

Month Day Year
Date
Medical History
Has your cat had a fecal test, and if so, what date?
Has your cat had a Leukemia/FIV blood test, and if so, what date?
Has your dog had a fecal test, and if so, what date?
Has your dog had a heartworm blood test, and if so, what date?
How many hours a day does your pet spend outdoors?
What type of flea and heart worm preventative are you currently using?
Any prior history of illness or surgery?
Is your pet currently on any medications? (Please indicate the dosage and duration.)
Does you pet have any drug allergies?
Any concerns regarding your pet’s behavior? (i.e. housebreaking/ litterbox training, digging, barking, inappropriate chewing)?
What does your pet eat? (Please indicate how much and how often.)
Does your pet receive any treats or extras? (Please explain.)
If you have already made an appointment at Lifetime, please tell us the date and time of your upcoming appointment.
Photo Release
I do hereby consent and agree that Lifetime Animal Care Center, its employees, or agents have the right to take photographs or digital recordings of my pet(s) and release all rights to exhibit this work in print and electronic form publicly or privately. I also understand that Lifetime Animal Care Center is not responsible for any expense or liability incurred as a result of the aforementioned participation in any photographs or recordings. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

Yes, I give permission for my pet’s photo to be used as noted above. No, please do not use my pet's photo.
I understand that I am financially responsible for all charges. If it becomes necessary to hire an outside agency to collect payment for my account, I agree to pay any and all collection charges, billing fees, and legal fees. Note that an $8.00 per month billing fee will be applied to all balances on account over 30 days.

Party responsible for authorizing and paying for services, please sign below.
Signature
Signature

Clear
Date

Month Day Year
Date
Professional fees are to be paid at the time that services are rendered. We accept Cash, Checks, Debit Card, Master Card, Visa, Discover, American Express and Care Credit

Thank you for allowing our hospital the opportunity to care for your pet!
Should be Empty:

Welcome to the Lifetime Family!

Pet Information

Vaccine History

Cats

Dogs

Medical History

Photo Release

Signature