Owner/Client InformationDo you already have a scheduled appointment?* Yes NoName* First Last Spouse NameAddress* 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 Primary phone*Secondary phoneEmail Address* Employer*Patient/Animal InformationName*Sex* Male FemaleBreed*DOB/AGE*Color*Markings*Spayed/Neutered?* Yes NoPrevious Veterinarian/Clinic*Is your pet current with vaccinations?* Yes NoIs your pet current with heartworm prevention?* Yes NoMedical InformationKnown Allergies*Known Reactions to Medications/Vaccinations*Previous Health Conditions*Is your pet on any medications?* Yes NoPlease list*Does your pet do well with other animals?* Yes NoPlease explain*What is the appointment for?*VaccinesSick/Injured VisitOtherIf this is an emergency, or your pet is in pain or injured, or you need an appointment today please call our office.1st Appointment Choice Date* MM slash DD slash YYYY Desired time Morning Midday Evening2nd Appointment Choice Date* MM slash DD slash YYYY Desired time Morning Midday EveningDoes your pet have a microchip?* Yes NoHow did you hear about us? Location/Sign Website Google Yelp Facebook Yahoo Twitter Instagram FriendWho can we thank?*Please note our cancellation policy: No-Shows and Cancellations made with less than a 24 hour notice significantly limits our ability to make the appointment available for another patient in need. Now shows and appointment cancellations with less than 24 hrs. notice may incur a charge equal to the cost of an office visit.Untitled* I acknowledge I have read and understand the cancellation policyYour privacy is important to us. We enjoy posting pictures of our amazing clients & patients on face book and other social media sites. We appreciate if you will give us permission to potentially use your name, pet’s name & picture on these sites. Typically we only use the pet’s first name in posts.Untitled* I acknowledge and agree to allow LVC to share about my pet (including photos) on social media.A member of our team will reach out to you after this form is submitted to coordinate your pet’s visit!CAPTCHAΔ
