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New Client Registration Form

Owner's Name *

First

Last

Co-Owner's Name (if applicable)

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Home Phone

Work Phone

Mobile Phone *

Co-Owner Work Number

Co-Owner Cell Number

Name of Previous Clinic

Previous Clinic Phone Number

Military?

Yes
No

Senior?

Yes
No

Who referred you? *

Place of Employment

Pet #1 Name *

Pet #1 Type *

Dog
Cat

Pet #1 Breed *

Pet #1 Microchip Number

Pet #1 Age/Date of Birth *

Pet #1 Color *

Pet #1 Sex *

Male
Female

Pet #1 Spayed or Neutered? *

Yes
No

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

Yes
No

Pet #2 Name

Pet #2 Type

Dog
Cat

Pet #2 Breed

Pet #2 Microchip Number

Pet #2 Age/Date of Birth

Pet #2 Color

Pet #2 Sex

Male
Female

Pet #2 Spayed or Neutered?

Yes
No

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

Yes
No

Pet #3 Name

Pet #3 Type

Dog
Cat

Pet #3 Breed

Pet #3 Microchip Number

Pet #3 Age/Date of Birth

Pet #3 Color

Pet #3 Sex

Male
Female

Pet #3 Spayed or Neutered?

Yes
No

I /we hereby authorize Lanoka Oaks Veterinary Center to request and record all previous medical records. I authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures. *

I have read and authorize

We love social media! Do we have your permission to share your pet(s) image and story on social media,our website & other forms of related media? Your name and personal information will never be shared. Simply check Yes to authorize. *

Yes, you have my permission.
No, you do not have my permission.

Owner's Signature *

Email

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