LAH New Client Form - updated 12-29-2021

LONGLEAF ANIMAL HOSPITAL SOUTHERN PINES, NC

New Client Registration Form
Name*

First NameLast Name
When is your Scheduled Appointment
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone
Email*
example@example.com - WE WILL ONLY EMAIL REMINDERS OR REBATE INFO
Primary Phone*

HomeCell
Owner Date of Birth

MonthDayYear
Date
* IF A CONTROLLED SUBSTANCE NEEDS TO BE DISPENSED THE PHARMACY REQUIRES THE OWNERS DATE OF BIRTH
Employer
Work Phone
Please enter a valid phone number.
Spouse/Co-Owner's Name
Spouse/Co-Owner's Phone Number
Previous Veterinarian

Pet 4 Info
4th Pet's Name
Pet 4 Dog or Cat

DogCat
Pet 4 Birthday/Age
Pet 4 Male/Female
Pet 4 Spay/Neuter
Pet 4 Breed
Pet 4 Color
Pet 4 Microchipped
Pet 4 Allergy - Is your pet allergic to anything?

YesNo
Pet 4 Vaccine - has your pet had a vaccine reaction?

YesNo
Get interactive with your pet’s health online!

By providing us with your email address, you will be invited to join Petly, a free interactive website to help you manage your pet’s health. With Petly you can request appointments, upload pictures, receive vaccine reminders, see medical history and more!! Longleaf AH will keep your email private.
- I hereby authorize the veterinarian to examine, prescribe for, treat, the above described pet(s).
- I assume responsibility for all charges incurred in the care of these pet(s).
- I UNDERSTAND PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED.
- I UNDERSTAND There will be a $25.00 fee for all returned checks
Signature
Should be Empty:

LONGLEAF ANIMAL HOSPITAL SOUTHERN PINES, NC