LaCroix Veterinary Hospital
Wilmington, NC Animal Hospital
Home
Back to Homepage
Services
Veterinary and pet care services
Remote Care
Bathing
Dental Care
Surgery Services
Spay & Neuter
Wellness Exams
Microchipping
Nutritional Counseling
Vaccinations
Emergency and Urgent Care Services
Puppy and Kitten Care
Senior Pet Wellness
Our Staff
Our talented vets and staff
Testimonials
Read what others have to say.
Contact Us
Phone, Email, Directions
Pet Records
Via AllyDVM
Online Store
Products for your pets’ care
Pay Online
Secure payment submission
Search for:
Home
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
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
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 >>