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info@russelllakevet.com
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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)
Friend or Relative
Google Search
Facebook
Instagram
Drove By
Staff Member
Shelter or Pet Store
Other
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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