New Client Form

Client Information

Pet Owner's Name *

Address *

City *

State * Zipcode *
What pronouns should we use for you? *

Occupation *

Email *

Preferred Phone *

Additional Phone

Partner or Co-owner's Name

Partner Phone

How did you hear about us?
---Friend or FamilyInternetYellow PagesDrive / WalkOther
If other...

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

Pet Information

Pet's Name *

Birthdate

Species *
---CatDog
Breed

Color

Sex
---MaleFemale
Is he or she spayed or neutered?
---YesNoI'm not sure
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 ---YesNoI'm not sure
Feline Distemper ---YesNoI'm not sure
Feline Leukemia ---YesNoI'm not sure
Has your cat had a Feline Leukemia and FIV test? ---YesNoI'm not sure
Does your cat go outside? ---YesNo

Dogs

Has your dog had the following vaccines?

Rabies ---YesNoI'm not sure
Canine distemper/Parvo ---YesNoI'm not sure
Bordetella ---YesNoI'm not sure
Lyme ---YesNoI'm not sure
Leptospirosis ---YesNoI'm not sure

Diet

What type of food does your pet eat?

Canned or dry? ---CannedDry

Preventatives

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

Allergies

Do you or does anyone in your home have a peanut allergy? (We use peanut butter to help distract dogs during exams.)
No,Yes

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)?

Yes, I consent to having my pet photographed and posted to the Lyndale Animal Hospital Facebook and/or Instagram account(s)

Let Us Know You're Human:

Δ