New Client Form

Lexington Pet Clinic New Client Form

Please fill out to the best of your ability prior to your exam. We can't wait to see you and your pet soon!
Client Contact Information
Full Name*

First NameLast Name
Primary Phone Number*
Cell Phone Number
E-mail
example@example.com
Would you like to include additional contact information?*

YesNo
Address*

Street Address or PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Information
How did you hear about us?
Personal Recommendation's Full Name

First NameLast Name
Other
Social Media Statement

Lexington Pet Clinic may ask to use photographs of your pet on our website, Instagram, or Facebook.

Additional Contact Information

Please include any family members or co owners that may be contacted about your pet
Contact 1

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Primary Owner
Please describe Contact 1's relationship to the owner
Contact 2

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Primary Owner
Please describe Contact 2's relationship to the owner

Animal Information
Pet Name*
Date of Birth*

MonthDayYear
Date
Species*
Breed*
Color/Markings*
Sex*

MaleFemale
Is your pet spayed or neutered?*

YesNo
Is your pet microchipped?*

YesNo
Microchip Number
Please submit your pet's medical records.

Cancelof
Your Pet's Previous Veterinarian (clinic, city, state)*
Please type N/A if your pet has never seen a veterinarian.
Do you wish to add another pet's information?*

YesNo

Payment is Required at Time of Service. Form of Payment Preferred: Cash, Visa, Mastercard, Discover

I understand that payment is due for services when rendered. I also understand that all unpaid balances are subject to monthly interest and service fees as well as a fee of 45% of the balance if turned over to collections.
Date of Appointment*

MonthDayYear
Date
Signature*

Clear
Today's Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Lexington Pet Clinic New Client Form