New Client Form

LAKES VETERINARY HOSPITAL

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New Client Form

* Indicates required field

Client Name *

First

Last

Fill our your first and last name.

Address *

Spouse/Other *

First

Last

Fill out first and last name of spouse/other.

Cell Phone Number *

Home Phone Number *

City *

State *

Zip Code *

Email *

May we e-mail you with reminders for your pet? *

How did you find us *

Friend (Whom may we thank?) *

First

Last

If a friend referred you to this clinic please put down his/her name so we may thank them.

Are you past/present Military? *

Yes No

If yes, we are happy to offer 10% discount with proof of service. Example: VA card, VFW card, Service Papers etc.

Reason for visit? *

Pet's Name *

Pet's Name

Age or Birth Date *

Enter your pet's approximate age or birth date.

Species *

Sex *

Breed *

What breed is your pet?

Declawed: *

Yes No

For cats. Is he/she declawed.

Vaccination History (Date and Type of Last Vaccinations). If unsure of Vaccination History, please list past Veterinary Clinic(s)/Hospital(s). : *

If you have records please bring them with you to your appointment.

May we contact the Veterinary Clinic you listed for records? *

Yes No

Upload any Vaccination Records or bring them with you to your appointment *

Max file size: 20MB

Please check any symptoms or problems that you have noticed about your pet: *

Bad Breath Behavior Problems Loss of Balance Scooting Scratching Shaking Head Eye Problem

Choose Any *

Not Eating Limping Weakness Coughing Diarrhea Sneezing Seizures Thirst and/or Increased Urination Vomiting

Choose Any *

Difficulty Breathing Sudden Weight Change Seems Depressed Gagging

Other Symptoms, please explain: *

Current Medication(s); and describe your pet's diet (Brand of food, treats, table food, etc.): *

Authorization
I hereby authorize the Veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges MUST BE PAID AT THE TIME OF RELEASE and that a deposit may be required for surgical treatment.

Signature of Owner/Agent: *

Date: *

Method of Payment *

Cash Care Credit Visa MasterCard Discover Check

Submit

Office Hours

Monday: 8 am - 5 pm
Tuesday: 8 am - 5 pm
Wednesday: 8 am - 5 pm
Thursday: 8 am - 5 pm
Friday: 8 am - 5 pm
Saturday: 8 am - Noon
Sunday: Closed

Contact Us

Phone: 218-864-5695
Fax: 218-864-5155
Email: lvhbattlelake@gmail.com

Click HERE to enter our on line pharmacy

602 S Olaf Ave, Battle Lake, MN 56515