"*" indicates required fields New Client FormAppointment Date* MM slash DD slash YYYY 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 Cell Phone NumberHome Phone NumberWhich number is best to reach you?* Cell Home Can you receive text messages?* Yes No Email* Driver's License Information* Driver's License Number AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Spouse / Co-Owner's Name First Last Spouse / Co-Owner's Phone NumberEmergency Contact Name First Last Emergency Contact Phone NumberEmergency Contact Relation I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable (your emergency contact must be an adult over the age of 18). Yes No Previous Veterinarian(s) Previous Veterinarian's Phone NumberPurpose of Visit*Establish CareNew Puppy or KittenSecond OpinionSick VisitWhom should we thank for referring you? Pet Health HistorySpecies* Canine Feline Pet's Name* Sex* Male Female Spayed/Neutered?* Yes No Unsure Breed* i.e. Dalmatian, German Shepherd, DSH (shorthaired cat), DLH (longhaired cat), etc.Color* i.e. Black/White, Tri-Color, Brown Tabby, etc.Date of Birth/Age* MM slash DD slash YYYY If you don't know the exact date, your best estimate is fine. Approximate Weight* Is your pet microchipped?* Yes No Unsure Does your pet have a social handle we can follow? Diet & EnvironmentAmount and frequency?* i.e. one 8 oz measuring cup twice daily, one solo cup one daily, etc. What food does your pet currently eat?* Please be as specific as possibleDoes your pet consume table food?* Yes No Is your pet primarily indoor or outdoor?* Indoor Outdoor Are there any other animals in the household?* Yes No Does your pet participate in any of the following:* Boarding Daycare Grooming Traveling None of the above Other If other, please explain* Past HistoryHas your pet had any prior illnesses, accidents, or surgeries?* Yes No If yes, please explainIs your pet on heartworm/flea/tick prevention?* Yes No If yes, please explainIs your pet aggressive or fearful around strangers?* Yes No If yes, please explainPlease list any other medications, preventivies, and/or supplements your pet receives.*Does your pet have any known allergies to any medications?* Yes No Has your pet ever had a reaction to any vaccines?* Yes No If yes, please explainPhoto Consent: Do we have permission to share your pet’s image on social media, our website or other forms of related media? Your name and personal information will never be shared.* Yes No I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment. In the event your account is placed for collection with an outside collection agency/attorney, you will be responsible for all costs of collection not to exceed 25%, which will be added to any unpaid balance.* I have read and agree to the above statement To allow for ample time for all patients and surgical procedures, Lindsay Veterinary Clinic operates primarily by appointment. We request all our clients be on time for scheduled appointments and procedures. For your protection and that of others, pets should be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet. If you must cancel an appointment, we ask for 24 hours’ notice. For surgical appointments, we ask for a 48-hour cancellation notice. We accept cash, debit, or all credit cards. We also offer Care Credit financing to help make the highest quality care accessible to all our patients. We would be more than happy to fill your prescriptions or have your food orders ready for pick-up. Please call ahead to process refills. Please allow 24 hours for prescription refills; special orders or controlled substances may require longer.I have read and agree to the above statements and policies.** Please InitialFile Upload: Add any previous records and/or a picture of your pet.Max. file size: 600 MB.Signature*Today's Date* MM slash DD slash YYYY Thank you for choosing Lindsay Veterinary Clinic! We look forward to treating your pet like a member of our Family! 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