Client Information:

Name *

First

Last

Email *

Home Phone *

I consent to receive SMS text messages from Lake Area Animal Clinic. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Work Phone

Driver's License Number: *

MUST SHOW PROOF OF A VALID DRIVER'S LICENSE UPON ARRIVAL

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your residential address the same as your mailing address? *

Yes
No

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

How will you be paying your bill today? *

I hear by authorize the veterinarian to examine, prescribe for, or treat my pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that all professional FEES ARE DUE AT THE TIME
SERVICES are rendered.

Signature *

Clear Signature

Signature of responsible party

Date *

Pet Health History: Pet # 1

Pet Name *

Birth Date or Age *

Sex *

Female
Female Spayed
Male
Male Neutered

Breed

Color

Current Medications your pet is taking

Prior Illnesses/Surgeries

Primary reason for visit

Did you adopt this pet from the Hill Country Human Society? *

Yes
No

Add an additonal pet information? *

Yes
No

Pet Health History: Pet # 2

Pet Name *

Birth Date or Age *

Sex *

Female
Female Spayed
Male
Male Neutered

Breed

Color

Current Medications your pet is taking

Prior Illnesses/Surgeries

Primary reason for visit

Did you adopt this pet from the Hill Country Human Society? *

Yes
No

Add an additonal pet information? *

Yes
No

Pet Health History: Pet # 3

Pet Name *

Birth Date or Age *

Sex *

Female
Female Spayed
Male
Male Neutered

Breed

Color

Current Medications your pet is taking

Prior Illnesses/Surgeries

Primary reason for visit

Did you adopt this pet from the Hill Country Human Society? *

Yes
No

Add an additonal pet information? *

Yes
No

Pet Health History: Pet # 4

Pet Name *

Birth Date or Age *

Sex *

Female
Female Spayed
Male
Male Neutered

Breed

Color

Current Medications your pet is taking

Prior Illnesses/Surgeries

Primary reason for visit

Did you adopt this pet from the Hill Country Human Society? *

Yes
No

New Client FormLake Area Animal Clinic

New Client Form

Client Information:

Pet Health History: Pet # 1

Pet Health History: Pet # 2

Pet Health History: Pet # 3

Pet Health History: Pet # 4

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Have a question?

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