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

                                Date ___________________

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