New Client Form - Glen Lake Animal Hospital

New Client Form

Owner Name

Spouse/Other

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Spouse Work Phone

Spouse Cell Phone

Previous Veterinary Clinic

Pet Name

Species

Canine

Feline

Breed

Color

Age/Date of Birth

Sex

Male

Female

Neutered/Spayed

Glen Lake Animal Hospital has my permission to take/use photographs of my pet for social media purposes.

Yes

Do you plan to return to Glen Lake Animal Hospital for your pet's primary care needs?
If you select "No," we will assume your new primary care clinic will provide all future reminders and preventive care notifications.

Yes

How would you like to receive reminders?

Mail

Both Mail and Email

We will gladly prepare a written estimate for services. Please ask the Technician/Receptionist or Doctor.

We accept Cash, Check, Visa, Mastercard, American Express, Discover or Care Credit.

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.