Name: Lake Area Animal Hospital
Telephone: +1-
Price range: $$

FIRST NAME(Required)

MIDDLE INITIAL:(Required)

LAST NAME:(Required)

MAILING ADDRESS:(Required)

Address(Required)

City State / Province / Region ZIP / Postal Code Country

HOME PHONE#:(Required)

CELL PHONE#:(Required)

WORK PHONE#:(Required)

EXT:

DRIVER’S LICENSE #:

EXP. DATE:

STATE:

E-MAIL ADDRESS:(Required)

Pet's Name(Required)

Species(Required)

DOG

CAT

HORSE

OTHER

Other pet(Required)

DATE OF BIRTH/AGE:

SEX:(Required)

BREED OR DESCRIPTION:

COLOR:

ANY PREVIOUS MAJOR ILLNESS, KNOWN ALLERGIES, OR MEDICATION REACTIONS:

PREVIOUS VETERINARIAN:

IS YOUR PET A SERVICE ANIMAL?

YES

I APPROVE THE USE OF NON CHILD PROOF CONTAINERS. INITIAL HERE

HOW DID YOU HEAR ABOUT LAKE AREA ANIMAL HOSPITAL?

CLIENT/FRIEND REFERRAL:

OTHER:

PHONE BOOK:

WE’RE HAPPY TO PROVIDE PET PORTAL FREE OF CHARGE TO ALL CLIENTS WHO HAVE AN ACTIVE EMAIL ADDRESS. PET PORTAL IS A SECURE, PRIVATE PET HEALTH WEBSITE THAT GIVES YOU A DIRECT ACCESS TO MANAGE YOUR PET(S) HEALTH 24/7.

TEXT MESSAGING TERMS AND CONDITIONS

1. TEXT MESSAGES SHOULD NOT BE RELIED UPON AS THE SOLE REMINDER. WE WILL CALL YOU THE NIGHT BEFORE YOUR APPOINMENT.

2. MESSAGE AND DATA RATES MAY APPLY.

3. WE ARE NOT RESPONSIBLE IF YOU DO NOT RECEIVE TEXT MESSAGES DUE TO ANY TECHNICAL OR SERVER DIFFICULTIES, PHONE CARRIER OUTAGES, OR DISCONTINUED SERVICE.

4. PLEASE BE ADVISED THAT ANYONE WHO HAS ACCESS TO YOUR PHONE WILL BE ABLE TO SEE YOUR REMINDER MESSAGE.

5. TEXT MESSAGES ARE BEING SENT BY PET PORTAL AND LAKE AREA ANIMAL HOSPITAL.

I HAVE READ AND AGREE TO THE TEXT MESSAGING TERMS AND CONDITIONS. INITIAL HERE

New Client Registration Form

Our Locations

Melrose Location

Hawthorne Location

New Client Registration Form

Our Locations

Melrose Location

Hawthorne Location

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