New Patient Registration Form

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Thank you for considering our hospital as your pet's provider for veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible before your pet's first visit. By filling out this form prior to your scheduled appointment you will help expedite the registration process and give us valuable insight in providing optimal care for your pet.

Client Information

Date *

YYYY

Date of your scheduled exam

YYYY

Client name (first and last) *

Email address *

Phone number *

Pet Health History

Pet name *

Species *

Canine

Feline

Other:

Breed *

Sex *

Male

Female

Male neutered

Female spayed

Age/Date of Birth *

YYYY

Has your pet been previously seen at a veterinary office? *

Yes

If yes, please list the name(s) of the veterinary clinic that your pet has previously been seen. Do we have your permission to contact the clinic and request your pet's records?

Has your pet had any adverse reactions to vaccines or medications? *

Yes

If yes, please describe the specific reaction.

Does your pet have any chronic conditions or previously diagnosed medical problems of which we should be aware? If so, please list:

Is your pet currently on any medications or supplements? *

Yes

If yes, please list any and all medications and supplements below:

Is your pet current on monthly flea/tick and heartworm prevention? *

Yes

If yes, please list the type of preventative that you have been giving your pet and the last day it was given.

Please include any other information about your pet that you would like our clinic to know.

Thank you for completing our New Patient Registration Form, we can't wait to meet your new furry family member. If you have any questions or concerns prior to your scheduled appointment please feel free to call our office at (315)673-4858 or send an email to contact@lcvetcare.com.

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