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Welcome to our hospital, Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following form.  * means required

 
Your Information

* Your Full Name  
Spouse's name if applicable  
* Mailing address  
* City  
* State  
* Zip code  
* Main phone number to reach you  
Work phone  
Cell phone  
Place of employment  
* Are you a seasonal resident?  
Email address  
* Reminder preference  

ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

Preferred payment method  
How did you become aware of our clinic?  
If other in previous please specify  
Personal recommendation
(whom may we thank)		  
     

Your Pet(s) Information
 

* Is there a veterinary clinic/hospital we can contact for previous vaccine or medical records?    
Clinic name if yes to above  
List any previous serious illness or surgeries  
Does your pet have any known allergies to vaccinations or medications?  
List any allergies if yes to above  
Is your pet on any special diet or medications?  
List any if yes to above  

* Pequot Lakes Animal Hospital practices both traditional (Western) and alternative medicine (Chinese herbs, acupuncture, holistic treatments). Are you interested in alternative medicine for your pet? *

Yes, I am interested in alternative medicine
No, I prefer to treat my pet with traditional medicine
I have no preference, please treat my pet with
     whatever therapy is necessary

 

Please enter the information below for up to three pets

Pet #1 Information
* Name  
* Breed  
* Birth date  
* Color  
* What sex is this pet?  
* Has this pet been spayed/neutered?  
Date of rabies vaccine  
Date of distemper vaccine  
Date of lyme vaccine (dog)  
Date of bordetella vaccine (dog)  
Date of leukemia vaccine (cat)  
Pet #2 Information
Name  
Breed  
Birth date  
Color  
What sex is this pet?  
Has this pet been spayed/neutered?  
Date of rabies vaccine  
Date of distemper vaccine  
Date of lyme vaccine (dog)  
Date of bordetella vaccine (dog)  
Date of leukemia vaccine (cat)  
Pet #3 Information
Name  
Breed  
Birth date  
Color  
What sex is this pet?  
Has this pet been spayed/neutered?  
Date of rabies vaccine  
Date of distemper vaccine  
Date of lyme vaccine (dog)  
Date of bordetella vaccine (dog)  
Date of leukemia vaccine (cat)  
     

 
When finished click Submit, to clear the form click Reset