Lyndale Animal Hospital New Client Form 2022

Client Information
Pet Owner's Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What pronouns should we use for you? *
Occupation *
Email *
example@example.com
Preferred Phone *
Additional Phone
Partner or Co-owner's Name
Partner Phone
How did you hear about us?
If other...
Referred by? (We would like to thank them!)
Pet Information
Pet's Name *
Birthdate

Month Day Year
Date
Species *
Breed
Color
Sex
Is he or she spayed or neutered?
If so... when?
Does your pet have any medical conditions (allergies, heart disease, etc)? Please list below:
Is your pet on any current medications? Please list below:
What is the name of your previous clinic?
Please have your pet's previous records faxed or emailed over a few days prior to your appointment, so our doctors have a chance to review. You can also attach them below.

Browse Files

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Vaccine History

Cats - Has your cat had the following vaccines?
Rabies
Feline Distemper
Feline Leukemia
Has your cat had a Feline Leukemia and FIV test?
Does your cat go outside?
Vaccine History

Dogs - Has your dog had the following vaccines?
Rabies
Canine distemper/Parvo
Bordetella
Lyme
Leptospirosis
Diet
What type of food does your pet eat?
Canned or dry?
Preventatives
Is your pet currently receiving Heartworm preventative?
Is your pet currently receiving a flea and tick preventative?
Allergies
Do you or does anyone in your home have a peanut allergy? (We use peanut butter to help distract dogs during exams.)
What form of payment will you be using?
Social Media Consent
Sometimes we like to share about our patients online! This will only be done with your consent, and will always be discussed with you beforehand. Do you consent to having your pet photographed and posted on the Lyndale Animal Hospital Facebook and/or Instagram account(s)?
Yes, I consent to having my pet photographed and posted to the Lyndale Animal Hospital Facebook and/or Instagram account(s) *

Yes
Let Us Know You're Human: *
Should be Empty:

Client Information

Pet Information

Vaccine History

Vaccine History

Diet

Preventatives

Allergies

What form of payment will you be using?

Social Media Consent