WELCOME TO

Lake Area Animal Clinic

**.Please fill out form & email to or print out and bring with you to your appointment**

Client Information:

Authorization:

I hereby authorize the veterinarian to examine, prescribe for, or treat my pet.  I assume responsibility for all charges incurred in the care of the animal.  I also understand that all professional FEES ARE DUE AT THE TIME SERVICES are rendered.

Pet Health History:Pet #1

Pet Name: type here Birth Date:

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Breed:                             Color

Sex:       Make        Neutered       Female      Spayed

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Current medications your pet is taking:

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Prior Illnesses/Surgeries:

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Primary reason for visit:

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Did you adopt this pet from Christ-Yoder Animal Shelter?               Yes           No

Thanks for submitting!