LVS New Patient Form

New Patient Form
This form is for clients who have an upcoming consultation appointment with Leshem Veterinary Surgery. If you don't have a scheduled appointment, please call (860) 693-6992 to make one. Please fill out this form as accurately as possible.
Owner Information
Primary Owner's Name*

First NameLast Name
Cell Phone Number*
Please enter a number where you can be reached and receive texts
Secondary Owner's Name (if applicable)

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License Number*
Issuing State of Driver's License*
Have you been to either the Veterinary Emergency Center or Leshem Veterinary Surgery with any animals in the past?*

YesNo
How did you hear about us?

Primary veterinarianInternet searchFriendSocial mediaDrive by/signOther
Pet Information
Pet's Name*
Species*
Breed*
Gender*
Age or birth date*
Color*
Is your pet up to date on their Rabies vaccine?*

YesNoUnknown
Primary Veterinary Hospital*
We will contact your primary veterinarian for all medical records. If you have any, please upload any related documents here (previous records, pictures, videos, etc.)

Cancelof
Reason for consultation appointment:
Consent
All dogs must be leashed and all cats secured in a carrier.

If you have a scheduled appointment you're welcome to come directly into the building when you arrive.

Our consultation fee is $195 and full payment is due for all costs at the time of services renedered. We accept most forms of payment with the exception of checks. Finally, we do reserve the right to refuse service for any reason.
Pet Owner's Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

New Patient Form

Owner Information

Pet Information

Consent