occurred list etc.)

Owner Name *

First

Last

Spouse/Other *

First

Last

Email *

Primary Phone *

Home Phone

Work Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

In case of EMERGENCY please call *

First

Last

Emergency Phone *

Professional fees are due at the time of service, and occasionally a deposit may be required prior to the services rendered. We will gladly provide you with a written estimate if you so desire. Please make your request to a staff member or doctor.

If you wish to pay by check please complete the following:

Driver’s License Number:

How did you hear about our hospital? *

I understand every effort will be made to achieve a successful outcome and to provide all possible safety measures in hospital care and handling. I hereby authorize Lakewood Forest Veterinary Hospital to receive, prescribe for, treat, or perform surgery upon the pet(s) listed on the reverse side. I understand that unforeseeable adverse reactions to treatments are always a possibility. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence of the qualified personnel may not be provided. *

I have read and accept service policies.

Animal Medical History

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Description (Color)

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Total number of pets in household (Dogs, Cats, Other)

Food Fed

Dry
Canned
Treats/Other

Percentage of time spent outdoors

Type of time spent outdoors

Free roaming
Supervised
Not always supervised
Yard

Is your pet currently taking any prescription medication?

Yes
No

Name / Dose (mg) / Start Date / Last given

Heartworm Preventative

Flea/Tick preventative

Please list any past medical or surgical problems and when they occurred

Previous Vet Hospital

Previous Vet Hospital Phone

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Description (Color)

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Food Fed

Dry
Canned
Treats/Other

Percentage of time spent outdoors

Type of time spent outdoors

Free roaming
Supervised
Not always supervised
Yard

Is your pet currently taking any prescription medication?

Yes
No

Name / Dose (mg) / Start Date / Last given

Heartworm Preventative

Flea/Tick preventative

Please list any past medical or surgical problems and when they occurred

Previous Vet Hospital

Previous Vet Hospital Phone

New Client Form

New Client Form

Animal Medical History

Schedule Your Pet’s Appointment

Have a Question?

Location

Contact Information

Hours