Lovers Lane Animal Medical Center New Patient Information Form
Welcome to Lovers Lane Animal Medical Center. Our staff is dedicated to the optimum patient care and will do its utmost to make you and your pets visit here as pleasant and beneficial as possible. Please feel free to ask any questions concerning the treatment of your pet or other policies of the clinic. To help us serve you better, please provide us with the following information
Name _____________________________________________ Spouse’s Name ____________________________________________
Address ____________________________________________________ City _______________ State _______ Zip _________
Home Phone _______________________________________ Cell ____________________________________
Place of Employment __________________________________________________ Work Number __________________________________
Spouse’s Place of Employment __________________________________________ Sp. Work Number__________________________________
Drivers License # ________________________________ SS# __________________________
Email Address _______________________________________________________________________________________________
How did you choose our practice? □ Yellow Pages □ Location □ Website
□ Personal Recommendation (whom may we thank?) _______________________________________
Any previous illnesses or surgeries? ______________________________________________________________________________________
Any allergies to vaccination or medications? _____________________________________________________________________________
Is your pet on any special diets or medications? _____________________________________________________________________________
In case of an emergency, when I, the owner cannot be reached; I agree to pay for such services, not to exceed $_____________ within a reasonable period.
I also authorize ___________________________________________________ (name), _______________________ (telephone#) to request emergency services for the post listed animals, and agree to pay for services, not to exceed the amount stated.
Finance charges will be assessed to overdue balance.
Signature of Owner or Agent