Annual Appointment History Form

Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.

We ask that one to two adults be present at your pet’s exam since our exam rooms are too small to accommodate many people.

The check-in and check-out processes for all visits will occur over the phone, so please provide the information below even if you intend to attend your pet’s appointment. Thank you!

Owner Name *

First

Last

Phone *

Email *

Pet's Name *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Would you like to accompany your pet into the clinic today, or would you prefer a curbside visit and a call from the veterinarian? *

In-person visit
Call

**We ask that only one to two adults be present at your pet’s exam since our exam rooms are too small to accommodate many people.**

Reason for visit: (check all that apply) *

Annual Physical
Heartworm/Tick test (dogs)
Fecal/intestinal parasite screen
Deworming treatment
Annual physical - unsure of other services that are due. Would like to discuss with veterinarian.

Feline Vaccines

FVRCP/Distemper
Rabies
Feline Leukemia (FeLV)
Unsure, would like to discuss recommendations with veterinarian

Other procedures: (All procedures at additional cost)

Anal glands
Nail trim
Ear cleaning

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

What brand and type of food do you feed your pet?

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often below)

Do you have insurance for your pet? *

Do you give your pet heartworm or flea/tick preventative? *

Do you wish to take home flea/tick/heartworm prevention today? *

Yes
No
Unsure, speak with a veterinarian about recommendations for my pet

What percentage of time does your pet spend outside?

Have you seen any fleas or ticks on your pet? *

Do you have other pets? *

Is your pet on any medications? *

Was your pet last seen by a veterinarian at Lake Road Animal Hospital? *

Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand

I give Lake Road Animal Hospital authorization to treat as discussed above. *

I have read and agree

Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days? *

Who experienced these symptoms?

Self
Someone else in the house
No symptoms

*If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment.

In-person visit: Please call or text our team when you arrive to check in. When the doctor is ready to examine your pet, a team member will escort you into the exam room. We ask that you remain seated during the exam and allow a trained patient handler to provide physical support to your pet. Wearing a mask is recommended. Once the exam has been performed and a plan has been discussed and approved with the veterinarian, we ask that you return to your vehicle while the doctor and nurses complete the services discussed (such as bloodwork, x-rays, or other therapies). As with curbside visits, we will call or send a secure link for payment after the visit is complete and bring your pet back to you. This will allow for proper cleaning time between patients to keep all of our patients, clients, and team members as healthy as possible. *

I have read and understand.

Drop off appointments: A drop off appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that there is an additional charge for this service as your pet will be cared for and housed in a kennel until they are able to be picked up. If you need to leave your pet for their appointment, please inform the team member who collects your pet from the car and the receptionist who answers the phone when you first arrive. *

I have read and understand.

Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above mentioned pet. *

I agree
I disagree

Please type your initials. *

Date *

Comment

Caring people who care for pets.

Address

3065 Lake Rd
Horseheads, New York, 14845
Click here for directions.

Hours

Mon: 8:00 am – 6:00 pm
Tue: 8:00 am – 6:00 pm
Wed: 8:00 am – 6:00 pm
Thur: 8:00 am – 6:00 pm
Fri: 8:00 am – 6:00 pm
Sat: 8:00 am – 1:00 pm

Contact & Connect

Phone (call or text): 607-733-6503
Fax: 607-733-3656
Email: [email protected]
Facebook
Instagram

Directions from Corning:

Take 17/86 east towards Binghamton
Take Exit 53 (Horseheads) exit and stay to the right
Go through two lights, and at the third light take a right onto South Main, this turns in to Lake Road
The hospital is ~1.5 mile on the right

Directions from Elmira – local roads:

Take Church St. or Water St.to the Madison Ave Bridge
Take a left on to Madison Ave, this turns in to Lake St, and then to Lake Rd.
Follow Lake St. to Lake Rd. past Curly’s Chicken, the hospital is ~1/2 mile on the left

Directions from Elmira – highway:

Take 17/86 West towards Horseheads/Corning
Take Exit 54 towards Horseheads/Rt 13
Stay to the left to exit towards Horseheads
At the light, take a left on to South Main which turns in to Lake Road
The hospital is ~1.5 mile on the right