New Client Information

New Client Information
OWNER INFORMATION
Name*

First NameMiddle NameLast Name
Preferred Contact*
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Name

First NameMiddle NameLast Name
Contact
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
(Business Name If Self Employed)
Work
Spouse Employer
(Business Name If Self Employed)
Work
Date of Birth*

MonthDayYear
Driver’s License
Email*
example@example.com
PET INFORMATION
IndoorOutdoorBoth
Pet's Name*
Breed*
Date of Birth

MonthDayYear
Color*
MaleFemale
YesNo
Hospital Name where last Vaccinated
Special Diets or Meds
Previous Illness/Surgery
YesNo
PET INFORMATION #2
IndoorOutdoorBoth
Pet's Name*
Breed*
Date of Birth

MonthDayYear
Color*
MaleFemale
YesNo
Hospital Name where last Vaccinated
Special Diets or Meds
Previous Illness/Surgery
YesNo
PET INFORMATION #3
IndoorOutdoorBoth
Pet's Name*
Breed*
Date of Birth

MonthDayYear
Color*
MaleFemale
YesNo
Hospital Name where last Vaccinated
Special Diets or Meds
Previous Illness/Surgery
DoctorReferralPersonal RecommendationSignYellow PagesDog/Cat ShowOther
Referral, By whom?
Name*
(Who may we thank for referring you?)
If Doctor
Clinic Name*
Clinic Phone Number
Format: (000) 000-0000.
Things you want us to know about your pet
Financial Policy

In order to maintain high quality veterinary care while keeping out cost under control

ALL FEES ARE DUE UPON COMPLETION OF SERVICES.
Please indicate you choice of payment*
Policy of Cancellation of Appointments/Media Release Initial
I authorize this Lytle Veterinary Clinic to acquire any medical or surgical records from my previous veterinarian and/or send copies of any medical or surgical records to any veterinarian and/or pet grooming shop as requested.
Signature*

Clear
Date*

MonthDayYear
Date
(At your request, we will gladly provide you with a written estimate of fees before care is provided.)
Policy on Cancellations of Appointments/No-show

When you do not show up for a scheduled appointment, it creates an unused appointment slot that could have been used for another patient. It is very important that you call within 24 hours in advance to cancel your appointment.
- Effective February, 2018 any client who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $25.00 fee. This fee must be paid prior to your next appointment. If for any reason you need to cancel an appointment, please notify our office as a soon as possible.
- Any client who fails to show or cancels/reschedules an appointment with no 24 hour notice a second time will be charged a $50.00 fee.
- If a third No Show or cancellation/reschedule with no 24 hour notice should occur the patient may be dismissed from Lytle Veterinary Clinic.
- The fee is charged to the client and is due at the time of the next rescheduling of the next office visit.
- As a courtesy, when time allows, we make reminder calls, emails and text message for appointments. If you do not receive a reminder calls, emails and text message, the above Policy will remain in effect.
Policy of Cancellation of Appointments*

Clear
Media Release Form
I grant to Lytle Veterinary Clinic Inc., its representatives and employees the right to take photographs, videos, or any other media of me and/or my pet(s). I authorize Lytle Veterinary Clinic Inc, its assigns and transferees to copyright, use and publish the same in print and/or electronically. (Lytle Veterinary Clinic Website, Facebook, Youtube, and other social media.)I agree that Lytle Veterinary Clinic Inc. may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Use media of me and/or my pet(s).Opt Out of all media usages.I understand that there will be no financial or other remuneration for any photograph, videos, or any other media of me and/or my pet(s).I waive my rights, claims, or interest I may have to control the use of my identity or likeness in any photograph, videos, or any other media of me and/or my pet(s). Unless opted out of all above.*
THE UNDERSIGNED HAS READ THE FORGOING RELEASE AND FULL UNDERSTAND IT.

Agreed and accepted by:
Signature*

Clear
Should be Empty:

New Client Information

OWNER INFORMATION

PET INFORMATION

PET INFORMATION #2

PET INFORMATION #3

Referral, By whom?

If Doctor

Financial Policy

Policy on Cancellations of Appointments/No-show

Media Release Form