New Client

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name and Email (required)
First Name (required)	Last Name (required)

E-Mail Address (required) :

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

Pet's Name (required)

Age: (required)

Type of Pet (required) :

Breed:

Color

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pet's vaccines current?
Yes
No

Do you have your pet's medical records?
Yes
No

Are your pet's medical records at another veterinary practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Check here if you would like us to call you to set up an appointment

Any special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Lakeside Animal Clinic and that charges are due and payable at the time of service. Any balance that I leave unpaid will be forwarded to Lakeside Animal Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to the maximum allowed monthly finance charges.

I have read this statement and - (required)
I Agree
I Disagree

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