LaCroix Veterinary Hospital
Wilmington, NC Animal Hospital
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Client & Pet Registration Form
Client & Pet Registration Form
Thank you for giving LaCroix Veterinary Hospital the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Client Registration
Owner's Name:
*
First
Last
Spouse/Housemate's Name:
First
Last
Email Address (for patient correspondence only)
*
Mailing Address
*
Street Address
Address Line 2
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ZIP Code
Cell Phone
*
Home Phone
Work Phone
Spouse/Housemate Phone
Owner's Occupation/Employer
If necessary, may we call you at work?
Yes
No
Spouse/Housemate Occupation/Employer
If necessary, may we call him/her at work?
Yes
No
Previous Veterinarian's Name and Address
How did you learn of our hospital?
*
Drove by
Internet
Phone Book
Advertisement
Personal Referral
Whom may we thank?
Please specify which advertisement
Pet Registration
Pet's Name
*
First
Breed:
*
Birth Date
*
Date Format: MM slash DD slash YYYY
Pet is a
*
Male Dog
Female Dog
Male Cat
Female Cat
Spayed/Neutered?
*
Yes
No
Color(s)
*
Where did you get your pet?
*
Breeder
Pound
Friend
Is your pet on heartworm and/or flea prevention?
*
Yes
No
Which ones?
What do you feed your pet?
*
Prescription Food
Commercial Food
Table Scraps
How often daily do you feed your pet?
Do you supplement with treats, vitamins, etc?
*
Yes
No
Which ones?
Pet is:
*
Inside Only
Inside/Outside
Outside Only
How many hours outside per day?
Fenced?
Yes
No
Is your pet microchipped?
Yes
No
Microchip Number and Company it's Registered With:
Please share your pet's history.
Ongoing health problems, include current medications, allergies, prior illness or trauma, behavior problems, personality "quirks", etc. Also please let us know any concerns you have regarding your pet.
We are now offering Remote Vet Care!
Learn more
here >>
Wilmington, NC Animal Hospital
Wilmington, NC Animal Hospital