Lebanon Small Animal Clinic - New Patient Form

"*" indicates required fields

Client Information

Reason for first visit*

(e.g. Sick Pet, Establishing Care, Annual Vaccines, Etc.)

Contact Name*

First Last

Contact Address*

Street Address Address Line 2 City State ZIP Code

Contact Email Address*

Contact Phone Number*

Alternate Phone Number

Co-Owner Name

First Last

Co-Owner Phone Number

Emergency Contact Name*

Emergency Contact Phone*

How did you hear about us?*

Pet Information

How many pets are you registering?*

More than 1

Pet Name*

Pet Species*

Pet Breed*

Color*

Pet Sex*

Pet Birthdate*

Please provide the name and contact information for your pet's most recent medical history*

Facility Name & Phone Number or Email

Does your pet have insurance?

Yes

Authorization

I hereby authorize the veterinarian to examine, prescribe for, and or treat, the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for certain treatments.

Signature*

Use your mouse or finger to draw your signature above

Date*

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