New Client Form - English – Los Angeles Veterinary Center

323-685-7131 info.laveterinarycenter@gmail.com

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A Message From Our Team Regarding COVID-19

New Client Form

Please note: this form is to be used if you have already scheduled an appointment. If you have not yet scheduled an appointment, please call us directly at 323-685-7131 and we’ll be here to assist you.

Primary Owner *

First

Last

Date of Birth *

Secondary Owner

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Contact Phone # *

Phone Type *

Home
Work
Cell

Alternate Contact Phone #

Phone Type

Home
Work
Cell

E-mail *

Can we send you text message notifications?

Yes, please!
No thank you.

If yes, Phone #:

Preferred Method of Communication: *

Call
Text
Email
Postal Mail

How did you learn about us? *

Walk/Drive-by
Here Previously
Internet
Yelp
Google
Friend/Relative

If friend/relative: whom may we thank?

Appointment Date and Time (if you do not have an appointment, please call us at 323-685-7131 to schedule today!)

Date

Time

Pet's Name *

Dog or Cat? *

Breed: *

Age/D.O.B: *

Color: *

Sex

Male
Female

Spayed/Neutered?

Microchip #

Previous Doctor/Clinic Name:

May we request records?

Vaccination History:

Upload Attachments (Ex: x-ray images or previous test results)

Click or drag a file to this area to upload.

Additional Attachments

Click or drag a file to this area to upload.

Can we use photos of your pet on Social Media?

I, the undersigned, owner or authorized agent of the above patient, hereby authorize the admitting veterinarian (and his designated associates/assistants) to administer such treatment as needed for the benefit of this patient. I also consent to the administration of such anesthetics as needed. I further understand that no guarantee of successful treatment is made. I also assume financial responsibility for all charges incurred to this patient, and agree to pay all such charges at the time the patient is released. PAYMENT IS DUE AT TIME OF SERVICE. *

I have read and understand.

Signature of Primary Owner/Agent: *

Today's Date *

Signature of Secondary Owner/Agent:

Today's Date

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