New Client Registration Form

Welcome to Horseshoe Lake Animal Hospital!

We value your confidence in us and look forward to serving the healthcare needs of your pet!

Appointment date:

Pet Owner’s Information

Last Name*

First Name*

Title

E-mail*


Address

County

Home Phone

Work Phone

Cell Phone

Spouse’s Name

How did you hear about our clinic?

If recommended, whom may we thank?

Pet Information

Name of Pet:

DogCatOther

If other, please specify

Breed:

Color/Markings:

Sex:

Date of Birth/Age:

Date of last known vaccination:

Type of vaccination:

Number of pets:
Dogs
Cats
Other

Reason for your visit today:

Emergency Contact Name:

Phone number

Method of Payment:

Do we have your permission to post photos of you or your pet on social media sites?

Driver’s License Number:

** We will need a Drivers License if paying by Check**

AUTHORIZATION

I HEREBY AUTHORIZE the veterinarians and staff of Horseshoe Lake Animal Hospital to examine, prescribe for, and/or treat the above-described pet. I assume responsibility for all charges incurred in the care and treatment of this pet. I also understand these charges will be PAID IN FULL at the time of discharge and that a deposit may be required.

Yes, I agree to these terms.