Registration

Owner's Name *

Date *

Address *

City *

State *

Zip *

Best Number to be Reached *

Cell Phone

Home Phone

Work Phone

Email Address *

How did you learn of our clinic? *

Other *

Can we feature your pet on our Facebook page or other social media? *

Yes

No

Initial *

Pet Health History

Name of pet *

Dog, cat, or other? *

Dog

Cat

Other

Other *

Breed *

Color *

Birthdate/Age *

Sex *

Male

Female

Is your pet spayed/neutered? *

Yes

No

Vaccine History or Titers(list date/type) *

Please check off if your pet has any of the following symptoms *

Other *

Pet's current medications *

Pet's current diet *

Authorization

I hereby authorize the veterinarian to examine, prescribe for, 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 surgical treatment.

Signature of owner *

Date *

Method of payment *

Cash

Check

Care credit

Mastercard

Visa

Amex

Discover

Rate Us:

Welcome to Lindernhurst Veterinary Hospital

Thank you for giving us the opportunity to care for your pet. We'll be happy to answer any questions you have about your pet's health. To ensure the best care possible, please take the time to fill in this form completely. Thank you!