New Client Form

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

We would like to occasionally email patient exam/vaccine reminders, dental specials and after-exam surveys. Your email address is kept private and not shared.

Cell Phone *

Home Phone

Work Phone

Primary Phone *

Home
Work
Cell

Do we have permission to text your cell phone number for appointment confirmation? *

Yes
No

May we text you information and pictures of your pet when they are in the hospital with us? *

Yes
No

May we share your pet's picture and name on our website and Facebook page? *

Yes
No

Co-Owner Name

Co-Owner Cell Phone Number

Co-Owner Work Phone Number

How did you find us?

Whom may we thank?

Please Explain.

Have you already made an appointment? *

Yes
No

If yes, what date is your appointment? *

Pet's Name *

Pet's Species

Canine
Feline
Other

If other, please explain.

Pet's Sex

Pet's Breed

Mixed breed?

Yes
No

Pet's Color

Markings

Approx. Age or Birthdate

Should we use caution when approaching? *

Yes
No

Please explain.

Is your animal aggressive towards other animals? *

Yes
No

Does your pet need a muzzle? *

Yes
No

Please explain.

Is your pet currently on any medications? *

Yes
No

Please list.

Has your pet been microchipped? *

Yes
No
Not Sure

Microchip Number *

Would you like a microchip implanted? *

Yes
No

Additional Comments

Add a second pet?

Yes
No

Pet's Name *

Pet's Species

Canine
Feline
Other

Please explain.

Pet's Sex

Breed *

Mixed breed?

Yes
No

Pet's Color

Markings

Approx. Age or Birthdate

Should we use caution when approaching? *

Yes
No

Please explain. *

Is your animal aggressive towards other animals? *

Yes
No

Please explain. *

Does your pet need a muzzle? *

Yes
No

Please explain. *

Is your pet currently on any medications? *

Yes
No

Please explain. *

Has your pet been microchipped? *

Yes
No

Microchip Number *

Would you like a microchip implanted? *

Yes
No

Is this your pet's first veterinary appointment? *

Yes
No

When was your pet last seen at a vet office? *

What is the name of the Veterinary Hospital where your pet was last examined and/or where can we obtain their medical records? *

What is the main health issue you would like to discuss with the doctor? *

Additional Comments

Thank you for choosing Los Feliz Small Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of our mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment choices. Payment Options you can choose from are: Cash, Check, Visa, MasterCard, Discover, American Express, or CareCredit.

I understand that Los Feliz Small Animal Hospital requires payment in full at time of discharge. Healthcare plans and surgeries estimated over $500.00 will require a 50% deposit to begin pet's treatment. *

I have read and understand.

I understand that my account may be charged 15% interest on all outstanding balances older than 30 days and that if my account goes 90 days past due it will be turned over to a collection agency. All returned checks may be charged a $40 return check fee. *

I have read and understand.

I authorize the staff of Los Feliz Small Animal Hospital to provide treatment for my pets. *

I have read and understand.

Audio & Video Recording Policy

To promote the safety of employees, clients, guests and visitors, as well as the security of its facilities, our animal hospital reserves the right to conduct audio and video surveillance of any portion of its premises at any time. Video cameras will be positioned in appropriate places within and around company buildings and premises.

Conversations in work areas and telephone conversations over business phones may be monitored or recorded as a part of normal business operations. Clients, visitors and guests understand that there is no expectation of privacy in connection with the use of this equipment or with the transmission, receipt, or storage of information in this equipment.

The only exceptions to this policy include private areas of restrooms, showers and dressing rooms, and there will not be any audio or video recording in those areas.

I acknowledge receipt of a copy and consent to this animal hospital’s policy on audio and video surveillance and expectations of privacy. I understand that by signing this acknowledgement, I acknowledge and consent to the policy. *

I have read and understand.

Digital Signature (Name) *

First

Last

Today's Date *

Pet's Name *

Los Feliz Small Animal Hospital is always happy to meet new pets and the people who love them. If you’re new to our practice, we welcome you! In an effort to provide your pet with veterinary care in a timely manner, we have made our Client/Patient Registration form available online.

Contact us with any questions!

Address

Hours

Contact Info