Please be sure to fill out the New Client Registration Form AFTER you have scheduled an appointment, thank you! We would like to know a little about you and your family. Please fill out below.Client/Owner Information:Owner Name* First Last Date of Birth* MM slash DD slash YYYY (Required for Dispensing of Controlled Substances) Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone #1*Phone #2*Email* Preferred method to contact you with pet health status:* Call Text Both Preferred method of receiving updates and reminders regarding your pet(s):* Email Text Both Secondary Contact:* First Last Relationship:* Phone*Email* Do you authorize the secondary contact listed to make medical decisions, including lifesaving and financial decisions, regarding your pet in the event we are unable to reach you?* Yes No How Did You Hear About Us?* Driving by Google Yelp Facebook Instagram NextDoor Referral Other If Referred by client, please list client name* If Other, please explain:* We would like to know about your furry family. Please fill out below.Patient/Pet Information:Pet #1Pet Name:* Species* Feline Canine Breed:* Color:* DOB* Sex* Male Female Spayed/Neutered* Yes No Microchipped:* Yes No Any Known Allergies:Pet #2Pet Name: Species Feline Canine Breed: Color: DOB Sex Male Female Spayed/Neutered Yes No Microchipped: Yes No Any Known Allergies:Pet #3Pet Name: Species Feline Canine Breed: Color: DOB Sex Male Female Spayed/Neutered Yes No Microchipped: Yes No Any Known Allergies:Pet #4Pet Name: Species Feline Canine Breed: Color: DOB Sex Male Female Spayed/Neutered Yes No Microchipped: Yes No Any Known Allergies:Content PermissionOccasionally, we like to post adorable pictures of our client’s pets to our Facebook/Instagram pages or on our website, Client privacy is of the utmost importance at Lakewood Pet Vet. Your First and last name will not be disclosed or printed at any time unless you wished to be tagged. We are asking for permission to share, print, post, and reference your pet’s name and picture only. I understand the above statement and I give staff permission to take photos of my pet(s) for records purposes and to publish those photo(s) for any lawful purpose, including but not limited to social media, website or promotional materials, and I waive any rights of privacy or compensation associated with the use of my pet’s/pets’ image(s).* Yes No Authorization for Treatment* I hereby authorize the staff of the Lakewood Pet Vet to render any treatment which is deemed necessary to my pet(s) health while in custody of the hospital. * I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with treatment. * I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person, over the phone, or through email * I understand that professional fees are to be paid at the time services are rendered and a deposit is required on all pets admitted to the hospital. Signature*Signature of:* Owner Agent Good Samaritan Date* MM slash DD slash YYYY Signature of Spouse (if applicable)Date MM slash DD slash YYYY