New Client 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.

COVID PROTOCOL UPDATE:
All appointments will be performed curbside at this time due to a potential COVID-19 exposure. Please bring a phone with you to the visit so that the veterinarian or nurse can call to discuss your pet’s visit and recommendations. We do require that a mask be worn whenever interacting with one of our team members. Thank you for helping us to keep each other safe.

Information about the pet we will be seeing:

Name *

Species *

Canine
Feline

Breed *

Color *

Date of Birth/Age *

Gender *

Female
Male

Spayed or neutered *

Any Known Allergies/Reactions? *

Is your pet’s Rabies vaccine up to date? *

Who was your pet’s previous veterinary clinic?

No prior veterinary clinics (new pet, puppy, etc)
Please list prior clinic(s):

When was the last time your pet was seen by a veterinarian?

Approximate date/year *

No prior veterinary visits *

Is your pet’s Rabies vaccine up to date?

Information about you:

Name *

Employer *

Spouse/Other

Spouse Employer

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary phone number *

Secondary number

Spouse phone number

Other Phone Numbers

Email Address *

I would like to receive my pet's reminders by email *

Credit Policy: We ask that all fees be paid at the time of service. We accept cash, personal checks (with identification), Visa, MasterCard, Discover, American Express, CareCredit, ScratchPay, and VetBilling Payment Plans. Exceptions must be cleared with the Practice Manager prior to service, and completion of a credit form will be required. Past due accounts are subject to late fees and those turned over to collection are subject to collection and/or legal fees. *

I have read and understand.

Ask about our flexible payment options, rewards program and Pet Health Savings Accounts.

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

Who should we contact to make medical decisions at your pet's appointment? *

Owner (Named Above)
Someone Else (Named Below)

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.

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)

Do you have insurance for your pet? *

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

Yes (specify product(s) and last time given)
No

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?

Yes (specify - fleas or ticks?)
No

Do you have other pets? *

Is your pet on any medications? *

When was the last time your pet was seen by a veterinarian? *

Approximate date/year
No prior veterinary visits

Please provide the name of your pet's prior veterinary clinic(s) *

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 understand.

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. *

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.

I have read and understand. Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

Please type your initials. *

Date *

Message

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