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:

Does your pet have medical records at another clinic? If so, please enter the name of the hospital where they can be obtained:

Vaccine History

Cats

Has your cat had the following vaccines?

Rabies
Feline Distemper
Feline Leukemia
Has you 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?

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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