Lakes Veterinary & Surgical Center

Thank you for choosing Lakes Veterinary & Surgical Center. Please take a moment to familiarize us with you and your pet. For your convenience you may print our Client Information Form and complete it before your pet's first appointment with us.

Date: _____________________

Owner Information

Last Name: _________________________ First Name______________________ Middle Name____________________

Other Names on Account: ____________________________________________________________________________

Email Address: ______________________________________________Driver's Lic #:____________________________

Mailing Address: ___________________________________________________________________________________

City: ____________________________________ State: _________________ Zip: _________________

Street Address (if different from above): __________________________________________________________________

Phone: (H) _____________________ (W) ____________________ Cell _______________________

Employer: ____________________________________________________________________________

Employer Address: _________________________________________________________________________________

City: ____________________________________ State: _________________ Zip: _________________

Do you or your spouse qualify for our senior discount (62 years or older)?: Yes

Previous veterinary hospital (if transferring): ______________________________________________________________

Pet #1 Information

Pet's name that we are seeing today: ________________________________________________________

Canine Feline Other __________________________________________________________

Breed: _____________________________________________ Male Female Color: ______________________________________________ Neutered Spayed

Date of Birth: _______________________ Age: ___________ Is your pet micro chipped? Yes No

Is your pet currently taking medication: Yes No

Name(s) of Medication: ________________________________________________________________________________

Pet #2 Information

Pet's name that we are seeing today: ________________________________________________________

Canine Feline Other __________________________________________________________

Breed: _____________________________________________ Male Female

Color: ______________________________________________ Neutered Spayed

Date of Birth: _______________________ Age: ___________ Is your pet micro chipped? Yes No

Is your pet currently taking medication: Yes No

Name(s) of Medication: ________________________________________________________________________________

How did you hear about us?

Phone Book Internet/Website Invitation Human Society Newspaper
Previous Client Saw Sign Welcome Basket Flyer
Referral. Please print first and last name of person who referred you?__________________________________________
Other ___________________________________________________________________________________________

For office use only: Client#_________ W/C R/C#_________ C/S Staff Initials_________

Payment is expected at the time of service. Method of payment for today’s services:

VISA Mastercard Discover Card Cash Check Care Credit