Pequot Lakes Animal Hospital

Personal Information

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Last(Required)

Email(Required)

Phone(Required)

Secondary Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse/Partner Name

First

Last

Phone

Are you a seasonal resident?

Yes

No

Reminder Preference

Mail

Email

How did you find out about our hospital? If you were referred by someone, who should we thank?

ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

Preferred Payment Method

Cash

Check

Visa/Mastercard

CareCredit

Pet Information

Pet's Name(Required)

Species (dog or cat)(Required)

Color(Required)

Breed(Required)

Pet's Information*

Pet Name(Required)

Breed(Required)

Color(Required)

Age/Date of Birth(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Date of Last Vaccines

Is there a veterinary clinic/hospital we can contact for previous vaccine or medical records?

Yes

No

Previous Veterinary Clinic/Hospital Name(Required)

List any previous serious illness or surgeries:

Does your pet have any known allergies to vaccinations or medications?(Required)

Yes

No

Is your pet on any special diet or medications?(Required)

Yes

No

Pequot Lakes Animal Hospital practices both traditional (Western) and alternative medicine (Chinese herbs, acupuncture, holistic treatments). Are you interested in alternative medicine for your pet?(Required)

Yes, I am interested in alternative medicine

No, I prefer to treat my pet with traditional medicine

have no preference, please treat my pet with whatever therapy is necessary

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