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Lake Country Client Information Form
Welcome to Lake Country Veterinary Care! Thank you for entrusting us with the care of your furry family member. Whether you are a new or existing client, we want to make sure we have your current contact information so we are able to communicate efficiently and better serve you.
You may contact our office by phone at (315)673-4858 or via email at
contact@lcvetcare.com
.
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Registration
Date
*
MM
/
DD
/
YYYY
Date of your scheduled exam
MM
/
DD
/
YYYY
Client(Owner)name (first and last)
*
Your answer
Driver's license number
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
New York
Other:
Zip code
*
Your answer
Email address
*
Your answer
Cell phone number
*
Your answer
Home phone number
Your answer
What is your preferred method of contact?
*
Email
Phone call
Text
Required
What is your preferred method for account reminders?
*
Email
Text
Employer
*
Your answer
Employer phone number
*
Your answer
Spouse/co-owner/family member you would like listed on your account
Your answer
I give consent to release information to the individual(s) listed above.
*
Consent
Decline
Not Applicable (N/A)
Spouse/Co-owners contact number
Your answer
How did you hear about our clinic?
*
Social media (Facebook, Instagram)
Web
Word of mouth
Other:
Required
Social Media
I hereby give Lake Country Veterinary Care permission to take photographs and videos of me and/or my pet for the purpose of posting on LCVC social media accounts - Facebook, YouTube, Twitter, Instagram, and clinic website.
*
Consent
Decline
Financial Policy
I am the person responsible for the animals brought in for care at Lake Country Veterinary Care. I understand that payment must be made in full at time of services. I also understand that if payment is not made, I will be liable for all finance charges applied to my account. I recognize that a deposit may be required before surgical treatment of my pet. In the event of default where it becomes necessary to place this account in the hands of a third party for collection, I understand and agree to pay all costs of collection, including reasonable attorney's fees and court costs.
*
I have read and understood the statement above
Other:
Lake Country accepts cash, check, Discover, Visa, Mastercard, Amex, Scratch Pay and Care Credit for payment
Please type your name below to verify you have read and understood this form and each of its parts.
*
Your answer
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