Pet Information

Pet's Name *

Species *

Canine
Feline

Breed

Color

Date of Birth/Age

Gender *

Male
Female

Spayed or Neutered? *

Yes
No

Any Known Allergies/Reactions? *

Yes
No

If Yes, please elaborate:

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

Who was your pet’s previous veterinary clinic? *

Would you like to add information for a second pet? *

Yes
No

Pet's Name *

Species *

Canine
Feline

Breed

Color

Date of Birth/Age

Gender *

Male
Female

Spayed or Neutered? *

Yes
No

Any Known Allergies/Reactions? *

Yes
No

If Yes, please elaborate:

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

Who was your pet’s previous veterinary clinic? *

Would you like to add information for a third pet? *

Yes
No

Pet's Name *

Species *

Canine
Feline

Breed

Color

Date of Birth/Age

Gender *

Male
Female

Spayed or Neutered? *

Yes
No

Any Known Allergies/Reactions? *

Yes
No

If Yes, please elaborate:

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

Who was your pet’s previous veterinary clinic? *

Owner Information

Owner Name *

First

Last

Spouse/Other

Home Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Which phone numbers would you like to share with us? *

Cellular
Landline
Work
Spouse

Cellular *

Landline

Work

Spouse phone number

Email *

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

Yes
No

Whom may we thank for referring you to us? (check one)

If they are clients at our hospital, whom may we thank?

Which staff member?

If Other, please elaborate how you found us

Credit Policy: We ask that all fees be paid at the time of service. *

I have read and understand

Please see our Payment Options

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

Yes
No

Does your pet have an Instagram handle? Feel free to share below if so. We would love to follow them from our hospital page! @russelllakevet

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 *

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Pet Information

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