Lakewood Animal Hospital (IL) - Client Registration Form

Client Registration Form

Thank you for choosing our clinic for your pet's needs. Please take a moment to complete this form so we may better serve you.
Client Information
Today's Date*

MonthDayYear
Date
Client Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Spouse's Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #
Please enter a valid phone number.
Cell Phone #*
Please enter a valid phone number.
Best Time to Reach You*
Text Messaging*

YesNo
Email*
example@example.com
Drivers License #
Place of Employment
Work Phone #
Please enter a valid phone number.
Spouse's Place of Employment
Spouse Work Phone #
Please enter a valid phone number.
How did you hear about our hospital?*

Yellow PagesRadioSignNewspaperInternetFriendOther
If friend, who can we thank?*
Payment Preference*

CashCheckDebit CardCredit CardCareCredit
Pet Information
Pet's Name*
Date of Birth*

MonthDayYear
Date
Breed*
Color*
Species*

DogCatOther
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Is this registration form for your dog?*

YesNo
Has your dog ever been vaccinated or tested for:
Rabies - 1yr or 3yr*

NoYes
If yes, where and when?*
Distemper (DHLP-P)*

NoYes
If yes, where and when?*
Heartworm*

NoYes
If yes, where and when?*
Intestinal Parasites (stool ck)*

NoYes
If yes, where and when?*
Other (Bordetella, Lyme, etc)*

NoYes
If yes, where and when?*
Is this registration form for your cat?*

YesNo
Has your cat ever been vaccinated or test for:
Rabies - 1yr or 3yr*

NoYes
If yes, where and when?*
Distemper (FVRCP)*

NoYes
If yes, where and when?*
Leukemia*

NoYes
If yes, where and when?*
Intestinal Parasites (stook ck)*

NoYes
If yes, where and when?*
Any significant medical history or known allergies?
I grant Lakewood Animal Hospital permission to use, reuse, publish, and broadcast in any and all social media photographs, radiographs, or video footage recorded at the hospital of me and/or my pet, in which I may be included with others. I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges accrued in the care of this animal presented by me or my agents. I also understand that the charges will be paid in full at the time of services rendered or at release and that a deposit may be required for surgical treatment or hospitalization. I understand that I am responsible for a returned check fee of $25. I agree to pay for the reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Client Registration Form

Client Information

Pet Information