Lakeland Veterinary New Client Form

Lakeland Veterinary New Client Form

Welcome to our veterinary service! Please fill out this form to register as a new client.
Client Information
Full Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Pet Information
Pet's Name*
Type of Pet*

DogCatOther
Breed*
Birth Date (can be approximate):*

MonthDayYear
Gender*

Male NeuteredMale IntactFemale SpayedFemale Intact
Pet's Name (#2)
Type of Pet

DogCatOther
Breed
Birth Date (can be approximate):

MonthDayYear
Gender

Male NeuteredMale IntactFemale SpayedFemale Intact
Pet's Name (#3) (Leave blank if n/a)
Type of Pet

DogCatOther
Breed
Birth Date (can be approximate):

MonthDayYear
Gender

Male NeuteredMale IntactFemale SpayedFemale Intact
Medical History

Please provide any relevant medical history for your pet(s).
Previous Records/Vaccination History - please upload here

Cancelof
Medical Conditions
Reason for Visit
Preferred Appointment Type*

In-Person Home VisitTelehealth ConsultationIn-Person Clinic visit (coming soon)
Preferred method of communication (fastest way for us to reach out to you)*

EmailTextPhone
I would like to receive text message updates. Message and data rates may apply. You can opt-out at any time by replying STOP.*

YesNo
Preferred Payment Method

Credit CardCash/CheckPet InsuranceCare Credit
Additional Comments
Should be Empty:

Client Information