Information about the pet we will be seeing: Name * Breed * Color * Date of Birth/Age * Any Known Allergies/Reactions? * If yes, please explain * Is your pet’s Rabies vaccine up to date? * Who was your pet’s previous veterinary clinic?
*Please bring any paperwork provided by the adoption agency, shelter, breeder, etc with you to their visit or text photos of the records to
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?
*If the vaccine was performed at a Rabies clinic, please bring the certificate of the most recent vaccination or text a photo of the certificate to
Name * Employer * Spouse/Other Spouse Employer Primary phone number * Secondary number Spouse phone number Other Phone Numbers Email Address * I would like to receive my pet's reminders by email * Whom may we thank for referring you to us? (check one) * If they are clients at our hospital, whom may we thank? * Staff Member * If other, please explain * 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. * 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? * Reason for visit: (check all that apply) * Other procedures: (All procedures at additional cost) * Have you noticed any issues/problems with your pet? Are there any concerns for the following: (check all that apply) Skin Masses (explain below) * If other, please explain * 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? * 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? * If yes, specify product(s) and last time given * Do you wish to take home flea/tick/heartworm prevention today? * What percentage of time does your pet spend outside? Have you seen any fleas or ticks on your pet? If yes, fleas or ticks? * Do you have other pets? * Does your pet come into contact with other dogs? Please check all that apply * Is your pet on any medications? * When was the last time your pet was seen by a veterinarian? * Approximate date/year * 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 give Lake Road Animal Hospital authorization to treat as discussed above. * Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days? * Have you or anyone in your house experienced the following symptoms in the past 14 days? Who experienced these 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. * 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? * Please type your initials. *