Lakeland New Client Registration Form

Registration

Welcome to Lakeland Veterinary Hospital! We would like to thank you for giving us the opportunity to care for your pet(s). We’ll be happy to answer any questions you have about your pet’s health! To insure the best care possible, please take a few minutes to fill out this form completely.
Owner Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Spouse/Co-Owner Name

First NameLast Name
Spouse/Co-Owner Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse/Co-Owner Employer
Emergency Contact Name
Emergency Contact Phone
Additional Information
How Did You Hear About Our Practice?

Other
Which hospital/doctor?
Which client?
Which employee?
Patient #1 Information
Pet #1 Name
Species

Other
Date of Birth (Or Approximate Age)
Breed
Color
Sex
Spayed/Neutered
Current on Vaccines
Any previous surgeries or serious illnesses/diseases?
Any allergies to vaccines or medications?
Is your pet on any special diets or medications?
Do you have more pets?
Patient #2 Information
Pet #2 Name
Species

Other
Date of Birth (Or Approximate Age)
Breed
Color
Sex
Spayed/Neutered
Current on Vaccines
Any previous surgeries or serious illnesses/diseases?
Any allergies to vaccines or medications?
Is your pet on any special diets or medications?
Do you have more pets?
Patient #3 Information
Pet #3 Name
Species

Other
Date of Birth (Or Approximate Age)
Breed
Color
Sex
Spayed/Neutered
Current on Vaccines
Any previous surgeries or serious illnesses/diseases?
Any allergies to vaccines or medications?
Is your pet on any special diets or medications?
Authorization
Do we have your authorization to email your pet’s vaccine reminders or other periodic reminders?
Do we have your authorization to fax or verbally transfer records to another veterinarian, boarding or grooming facility, upon their request?
I grant LVH permission to post my pet’s picture, story and/or medical information on social media (when applicable).
I hereby authorize the veterinarian to examine, prescribe for or treat the above described pets. I assume responsibility for all charges incurred in the care of these animals. I understand that these charges must be paid at the time of release and a deposit may be required for treatments.
Today's Date

MonthDayYear
Date
For your convenience, we accept Cash, Checks, Visa, MasterCard, Discover, American Express and CareCredit.
Should be Empty:

Registration

Additional Information

Patient #1 Information

Patient #2 Information

Patient #3 Information

Authorization