New Client Form
Owner Information
Full Name
*
Preferred Pronouns (Optional):
Partner/Co-Owner Full Name (if Applicable):
Preferred Pronouns (Optional):
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Phone Number Type:
*
Please Select
Mobile
Home
Work
Secondary Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number Type:
Please Select
Mobile
Home
Work
Email
*
example@example.com
How Did You Hear About Us:
Google
Social Media
Friend/Family
Other Vet
Drive-By/Sign:
Other
If Friend/Family selected above, can you share the name below (if comfortable doing so):
Preferred Contact Method:
*
Email
Text
Phone
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Previous Veterinarian Information
Name of Veterinary Hospital
*
Phone Number of Veterinary Hospital
Name of Any Other Veterinary Hospital(s) Visited Within the Past 5 Years
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Pet(s) Information
Use the "+Add Row" for any additional pets to add.
Pet 1
*
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Social Media Consent
I give permission to LTAH to photograph and/or record my animal(s).
I agree that LTAH may post images and/or recordings of my animal(s) to the LTAH website, Facebook, or Instagram account.
I agree that LTAH may use these images for marketing and/or educational purposes.
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Financial Policy Agreement
Payment is due at time of service. We accept cash, major credit cards, and checks. Returned checks may incur fees. We do not offer billing or payment plans. Estimates available upon request.
I have read and understand the financial policy
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Consent for Treatment
I authorize the veterinarians and staff at Lake Tails Animal Hospital to examine and treat my pet(s) and assume full responsibility for all charges incurred.
I consent to treatment
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: