New Client Form

    Client Information

    Pet Owner's Name *

    Address *

    City *

    State * Zipcode *
    Preferred Gender Pronoun*

    Occupation *

    Email *

    Preferred Phone *

    Additional Phone

    Partner or Co-owner's Name

    Partner Phone

    How did you hear about us?

    If other...

    Referred by? (We would like to thank them!)

    Pet Information

    Pet's Name *

    Birthdate

    Species *

    Breed

    Color

    Sex

    Is he or she spayed or neutered?

    If so... when?

    Does your pet have any medical conditions (allergies, heart disease, etc)? Please list below:

    Is your pet on any current medications? Please list below:

    What is the name of your previous clinic?

    Please have your pet's previous records faxed or emailed over a few days prior to your appointment, so our doctors have a chance to review. You can also attach them below.

    Fax: 612-872-7813 | Email: info@lyndaleanimalhospital.com

    Vaccine History

    Cats

    Has your cat had the following vaccines?

    Rabies
    Feline Distemper
    Feline Leukemia
    Has your cat had a Feline Leukemia and FIV test?
    Does your cat go outside?

    Dogs

    Has your dog had the following vaccines?

    Rabies
    Canine distemper/Parvo
    Bordetella
    Lyme
    Leptospirosis

    Diet

    What type of food does your pet eat?

    Canned or dry?

    Preventatives

    Is your pet currently receiving Heartworm preventative?
    Is your pet currently receiving a flea and tick preventative?

    Allergies

    Do you or does anyone in your home have a peanut allergy? (We use peanut butter to help distract dogs during exams.)

    What form of payment will you be using?

    VisaMastercardDiscoverCareCreditCheckCash

    Social Media Consent

    Sometimes we like to share about our patients online! This will only be done with your consent, and will always be discussed with you beforehand. Do you consent to having your pet photographed and posted on the Lyndale Animal Hospital Facebook and/or Instagram account(s)?

    Let Us Know You're Human:

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