Lakewood - Client Registration Form

Client Information
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 This question requires a valid date format of MM/DD/YYYY.

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Last

First

Middle

Date of Birth This question requires a valid date format of MM/DD/YYYY.

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Spouse's Name

Date of Birth: This question requires a valid date format of MM/DD/YYYY.

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Street Address

City

State

Zip

Home Phone #

Cell Phone #

Best Time to Reach You

Text Messaging

Email Address This question requires a valid email address.

Drivers License #:

Place of Employment

Work Phone #

Spouse's Place of Employment

Work Phone #

How Did You Hear About Our Hospital?

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Payment Preference

Pet Information

Pet's Name

Date of Birth

Breed

Color

Species

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Sex:

Spayed/Neutered

Has Your Dog Ever Been Vaccinated or Tested For:

Has Your Cat Ever Been Vaccinated or Tested For:

Rabies - 1yr or 3yr

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Distemper (FVRCP)

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Leukemia

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Intestinal Parasites (stool ck)

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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.

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