New Client Form

Owner's First/Last Name* This field is required.It's nice to meet you!

First Name

Last Name

Owner's Date of Birth* This field is required.Please provide your date of birth.

Spouse or Authorized UserWould you like to add your spouse or another authorized user? By adding authorized users, you are allowing access to your account information, your pet(s) information, authorize any services needed, able to drop off/pick up your pet, and pick up medication. If you have more than one authorized user, let us know at check-in and we can add them to your account!

First Name

Last Name

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

What's the best number to reach you at?* This field is required.

Area Code

Phone Number

Spouse/Other NumberIs there a secondary number we can contact if needed? Want to add more numbers? Let us know at Reception!

Area Code

Phone Number

What is your email?This is a perfect way for us to send you reminders and promotions!

example@example.com

What is your preferred method of contact?* This field is required.Let us know which way is the best way to reach you.

Call

Text

Other

Were you referred by an existing client? If so, who?We'd love to say 'Thank You!'

Pet's Name* This field is required.

Pet's Date of BirthDon't know? Take a guess. We'll help you figure it out!

What kind of pet do you have?* This field is required.We love them all!

What breed is your pet?

Is your pet male or female?

Is your pet spayed or neutered?Tip: Neutering is for males, spaying is for females.

YESNO

What color is your pet?Any identifying markings?

Any allergies or chronic conditions?* This field is required.

Does your pet have Pet Insurance?* This field is required.If yes, please provide us with a blank claim form upon arrival.

YESNO

If you answered 'Yes' to having Pet Insurance, what is the name of the insurance company?Some popular ones are Trupanion, Embrace, Nationwide, Healthy Paws, etc.

Who is your pet's previous veterinarian?If none, you can skip this! If your pet has seen more than one veterinarian, please list all vets and their City/State.

Does your pet have any of the following medical concerns?* This field is required.Please click all that apply

Skin (rashes, itching, lumps, losing fur)

Limping or favoring limbs

Head shaking or ear infections

Vomiting or diarrhea

Trouble breathing

Coughing, wheezing, or sneezing

Eye or nasal discharge

Seizures

Not eating or drinking

Lethargy

Bad breath

Urinary concerns (ex: excessive urination, small urine amounts, not urinating, etc)

None

Other

Is there anything else we should know about your pet so we can make sure to provide them with the best possible care?

Do you have any other pets?

YESNO

Pet's Name* This field is required.

Pet's Date of Birth

What kind of pet do you have?* This field is required.We love them all!

What breed is your pet?

Is your pet male or female?

Is your pet spayed or neutered?Tip: Neutering is for males, spaying is for females.

YESNO

What color is your pet?Any identifying markings?

Any allergies or chronic conditions?* This field is required.

Does your pet have Pet Insurance?* This field is required.If yes, please provide us with a blank claim form upon arrival.

YESNO

Who is your pet's previous veterinarian?If none, you can skip this! If your pet has seen more than one veterinarian, please list all vets and their City/State.

Does your pet have any of the following medical concerns?* This field is required.Please click all that apply

Skin (rashes, itching, lumps, losing fur)

Limping or favoring limbs

Head shaking or ear infections

Vomiting or diarrhea

Trouble breathing

Coughing, wheezing, or sneezing

Eye or nasal discharge

Seizures

Not eating or drinking

Lethargy

Bad breath

Urinary concerns (ex: excessive urination, small urine amounts, not urinating, etc)

None

Other

Do you have any other pets?

YESNO

Pet's Name* This field is required.

Pet's Date of Birth

What kind of pet do you have?* This field is required.We love them all!

What breed is your pet?

Is your pet male or female?

Is your pet spayed or neutered?Tip: Neutering is for males, spaying is for females.

YESNO

What color is your pet?Any identifying markings?

Any allergies or chronic conditions?* This field is required.

Does your pet have Pet Insurance?* This field is required.If yes, please provide us with a blank claim form upon arrival.

YESNO

Who is your pet's previous veterinarian?If none, you can skip this! If your pet has seen more than one veterinarian, please list all vets and their City/State.

Does your pet have any of the following medical concerns?* This field is required.Please click all that apply

Skin (rashes, itching, lumps, losing fur)

Limping or favoring limbs

Head shaking or ear infections

Vomiting or diarrhea

Trouble breathing

Coughing, wheezing, or sneezing

Eye or nasal discharge

Seizures

Not eating or drinking

Lethargy

Bad breath

Urinary concerns (ex: excessive urination, small urine amounts, not urinating, etc)

None

Other

Lakeside Animal Hospital - Pet/Payment Policy* This field is required.If you are dropping off your pet for any reason, all patients must be current on vaccines. All dogs must have a current Rabies vaccine, fecal, Distemper/Adenovirus/Parainfluenza/Parvo, and a Leptospirosis vaccine given within the past year, and a Bordetella vaccine given within the past six months. All cats must have a current Rabies vaccine, Feline Rhinotracheitis/Calici/Panleukopenia/Chlamydia vaccine, triple test, and a fecal within the past year. If any internal and/or external parasites are found, your pet will be treated at your expense. Any time your pet receives a Distemper/Adenovirus/Parainfluenza/Parvo vaccine or Feline Rhinotracheitis/Calici/Panleukopenia/Chlamydia vaccine, an exam will be required and an exam fee will be added, as those specific vaccinations are a modified live virus and require doctor to monitor when given. ALL FEES ARE DUE AT THE TIME OF SERVICE! We accept cash, debit, and all major credit cards. We will gladly accept Care Credit in ANY amount. We ONLY offer 6 months no interest for amounts of $200 or more. We also accept Scratchpay. We DO NOT accept checks! An estimate for care will be provided for all emergencies, hospitalizations, surgeries, in any cases that require extensive treatment, or upon request. A deposit prior to treatment may be required and is at the hospital's discretion. NO SHOW/LATE CANCELLATION POLICY: We understand that circumstances happen but request that if this is the case you please contact us with at least 24 hours advance notice to cancel your pet’s appointment. By doing so you free a space for another pet in need of care. Clients who miss an appointment without 24 hours advance notice will be considered a “no show” and will be subject to a No Show Fee added to the cost of their next appointment or, alternatively, will forfeit their deposit for their pet(s) visit if a deposit/credit has been applied to their account. If an appointment falls on a Monday or day after holiday, a message left via voicemail, text, or PetDesk App will qualify as adequate notice. This policy has been established to provide the highest level of veterinary care to our patients. We do understand that emergencies arise and that it may not be possible to give such a notice. Exceptions to the No-Show/Late Cancellation Policy will be determined by management. Thank you for your cooperation. PRESCRIPTION POLICY Lakeside Animal Hospital has an on-site pharmacy and can dispense most medications for your pet. If you elect to use an outside pharmacy for your prescription medications or if a medication is not carried in our pharmacy, a written prescription will be provided for you upon request. If you choose to use an outside pharmacy to obtain your pet's medications: I understand it is my responsibility to use a properly licensed pharmacy and verify the authenticity of any products received from a third-party pharmacy. BOARDING POLICY Any boarding in conjunction with a surgery or dental will include an additional fee of $5/night for each night of post-operative care. We require a signed estimate and full pre-payment of any surgical or dental procedure to be performed during the boarding reservation. If a surgery or dental is scheduled during boarding and the patient is sharing kennels with another pet, they will be separated into two kennels post surgery. We require a deposit for any holiday boarding or any boarding reservations longer than (1) week at the time of booking. If the boarding reservation is cancelled within 48 hours of the reservation date, the deposit is non-refundable.

We love taking pictures! Do we have your permission to photograph your pet(s) during their visit and use it on our social media platforms (Facebook, Website, etc)?* This field is required.

YESNO

Signature* This field is required.Please complete your new client registration by signing below!

Clear

UploadIf you have your pet's medical records, please attach them here!

New Client Form