new client info form

	Lakeside Veterinary Clinic 18 Lake Simond Rd Tupper Lake, NY 12986 Phone: 518-359-7924 Fax: 519-359-7967
NEW CLIENT INFORMATION FORM
Thank you for giving Dr. Scranton the opportunity to care for your pet(s). Please complete the following information:
		Date: ___________________________________
Pet Owner _______________________________ Spouse's Name _____________________________ Street ________________________ City _________________________ State ____ Zip __________ Home Phone _________________________ Cell Phone ____________________________ Place of Employment ___________________________________ Phone ________________________ Spouse's Place of Employment _____________________________ Phone _______________________ Best time to reach you: _______________________________________________ Home Work
ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
Please indicate choice of payment: Cash/Check Visa/MasterCard How did you become aware of our clinic?Client Referal Internet Yellow Pgs Drove By Other If referred by a current or previous client, who may we thank? __________________________________
Patient Information for Pet # 1 Name______________________ Type of Animal _________________ Breed___________________ DOB_________________Sex: Male, Neutered? Yes No ---- Female, Spayed? Yes No Color _______________________ Our pet is a member of our family child's pet backyard pet Any previous illnesses or surgeries? _____________________________________________________ Any allergies to vaccinations or medications? _____________________________________________ Is your pet on any special diets or medications? ___________________________________________
Patient Information for Pet # 2 Name______________________ Type of Animal _________________ Breed___________________ DOB_________________Sex: Male, Neutered? Yes No ---- Female, Spayed? Yes No Color _______________________ Our pet is a member of our family child's pet backyard pet Any previous illnesses or surgeries? _____________________________________________________ Any allergies to vaccinations or medications? _____________________________________________ Is your pet on any special diets or medications? ___________________________________________
Patient Information for Pet # 3 Name______________________ Type of Animal _________________ Breed___________________ DOB_________________Sex: Male, Neutered? Yes No ---- Female, Spayed? Yes No Color _______________________ Our pet is a member of our family child's pet backyard pet Any previous illnesses or surgeries? _____________________________________________________ Any allergies to vaccinations or medications? _____________________________________________ Is your pet on any special diets or medications? ___________________________________________