LFPC New Client Form
Welcome to Lakeville Family Pet Clinic! Please fill out the form prior to your appointment.
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Client Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State / Province
Postal / Zip Code
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Pet Information
Pet's Name
*
Type of Pet
*
Dog
Cat
Breed
*
Date of Birth
*
/
Month
/
Day
Year
Date
Estimated DOB
Yes
Gender
*
Male
Female
Is Your Pet Spayed or Neutered
*
Yes
No
Unsure
When was the Approximate Date of Your Pets Last Heat Cycle?
-
Month
-
Day
Year
Indoor or Outdoor Cat
*
Indoor
Outdoor
Both
Is Your Pet on any Preventatives?
*
Yes
No
What Type(s)?
HeartGard
NexGard
NexGard Plus
Other
What Type(s)?
Type option 1
Type option 2
Type option 3
Type option 4
Where Do You Purchase Your Preventative?
Is the Preventative Given Year Round?
Yes
No
Which Months are the Preventative Given to Your Pet?
i.e. only May-August.
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Medical History
Please provide any relevant medical history you may have for your pet.
Reason for Visit
*
Current Diet
*
Include brand name, flavor, amount fed, etc. for all treats and meals
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Noticeable Changes
We consider a change to be noticeable if it has occurred within the past 30 days.
Have You Noticed Any Changes in Your Pets Appetite?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Water Consumption or Thirst?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Urination Patterns?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Defecation Patterns?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Behavior?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Energy Levels?
*
Yes
No
Explain
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Please list any previous veterinary clinics that have cared for your pet.
*
Vaccination/Previous Clinic Records (if available)
Browse Files
Drag and drop files here
Choose a file
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Any Known Medical Conditions or Allergies?
*
Is Your Dog on Any Current Medication(s)?
*
Yes, 1
Yes, 2
Yes, 3+
No
Name of Medication
Dosage
Include if the medication is given as needed.
When was the Medication Last Given?
Name of Medication 1
Dosage Med 1
Include if the medication is given as needed.
When was Medication 1 Last Given?
Name of Medication 2
Dosage Med 2
Include if the medication is given as needed if applicable.
When was Medication 2 Last Given?
Name of Medication 1
Dosage Med 1
Include if the medication is given as needed.
When was Medication 1 Last Given?
Name of Medication 2
Dosage Med 2
Include if the medication is given as needed.
When was Medication 2 Last Given?
Name of Medication 3
Dosage Med 3
Include if the medication is given as needed.
When was Medication 3 Last Given?
Include Any Other Medications here:
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Behavioral Notes:
Please let us know if your pet is dog-aggressive, bites, dislikes having their feet touched, is anxious, or has any other behavioral concerns similar. This will help our staff ensure your pet’s appointment is as comfortable and accommodating as possible.
What Can We Do To Make This Appointment Go As Well As Possible For You?
Additional Medical Concerns:
Additional Comments:
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Appointment Preference
Appointments may be subject to varying availability depending on our scheduling requirements and current openings. Preferred appointment times may not be available.
List your preferred appointment date.
/
Month
/
Day
Year
Date
List your second preferred appointment date.
-
Month
-
Day
Year
Date
List your third preferred appointment date.
-
Month
-
Day
Year
Date
Please list any time restrictions.
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Submit
Please verify that you are human
*
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