Lakeside Animal Clinic

2501 South Kirkwood
Houston, TX 77077

(281)493-9995

lakesidevets.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Co-owner/Significant Other/Relative (Can make medical decisions)
First Name
Last Name
Secondary/ Co-owner E-Mail Address :
Primary Mailing Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Primary Phone (required)
Phone TypePhone Number (required)
Secondary Phone
Phone TypePhone Number
Co-Owner Phone
Phone TypePhone Number
Pet's Name (required)

Age: (required)

Type of Pet (required) :
Breed:

Color

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pet's vaccines current?
Yes
No


Do you have your pet's medical records?
Yes
No


Are your pet's medical records at another veterinary practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Check here if you would like us to call you to set up an appointment
Any special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Lakeside Animal Clinic and that charges are due and payable at the time of service. Any balance that I leave unpaid will be forwarded to Lakeside Animal Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to the maximum allowed monthly finance charges.
I have read this statement and - (required)
I Agree
I Disagree



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