Lakeside Veterinary Clinic

18 Lake Simond Rd

Tupper Lake, NY 12986

Phone: 518-359-7924 Fax: 519-359-7967

NEW CLIENT INFORMATION FORM

     
Date: ___________________________________

Pet Owner _______________________________ Spouse's Name _____________________________

 

Mailing:

 

St________________________ 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

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? ___________________________________________