New Patient Form Fill out our online form or download a printable version Name First Last Spouse/Signif. Name First Last Child's Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary PhoneSecondary PhoneOtherEmail (used for reminders and updates) To allow us to maintain our high standards of veterinary medicine, full payment is required at the time of service. How will you be taking care of your account today? Cash Credit Card Care Credit Patient InformationName Breed Colors Age Sex Allergies Add another pet? Yes No Name Breed Colors Age Sex Allergies Add another pet? Yes No Name Breed Colors Age Sex Allergies Add another pet? Yes No Name Breed Colors Age Sex Allergies Regarding overall health issues, do you regard your pet as: Family, I am interested in all wellness and healthcare issues A pet, I am not interested in all wellness and healthcare issues Since we are a full service veterinary facility and practice integrated medicine, are you interested in or want information about… Acupuncture (certified) Boarding at Lifetime Pet Wellness Center Cryosurgery Dental care Flea/tick prevention Grooming at Lifetime Pet Wellness Center Herbal medicine-Chinese or Western Homotoxicology (a form of homeopathy) HW/intestinal parasite control Laser surgery Laser therapy Nutritional medicine Specialty or Holistic diets Spinal Manipulative Therapy (certified) Training or behavioral classes Ways to extend your pet’s life How did you hear from us? Personal friend, relative, etc. (who should we thank?) Social Media Sign (drove by) Newspaper ad/article New resident program/ Welcome Wagon Pet store/humane society Direct mail or coupon Civic or community event If referred by a friend or relative who should we thank with a $20 coupon? Which social media? Instagram Facebook Twitter Which newspaper ad/article? Which pet store/humane society? Which civic or community event? Appointment reservation fee notice: Each client’s appointment is important to us. We want to give your service the time and attention it deserves. As a result, credit card numbers will be used to reserve appointments for new clients, grooming appointments, boarding appointments, and appointments for multiple pets in the same time frame. We respectfully require at least a 48 hour notice if you need to cancel or make changes to your appointment time. Failing to give 48 hour notice will result in a 50% charge. Any no-shows will be charged 100% of their service amount. Boarding no shows will be charged the full amount of the first day. Being more than 10 minutes late for a medical appointment may require rescheduling of the appointment and a no show charge. Date MM slash DD slash YYYY CAPTCHA Δ
