Home
Services
Who We Are
Contact Us
(910) 799-3100

Select Page

New Client 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:

Owner's Name:(Required)

First Last

Spouse/Housemate's Name:

First Last

Email Address (for patient correspondence only)(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

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?(Required)

Drove by

Internet

Phone Book

Advertisement

Personal Referral

Other

Whom may we thank?

Please specify which advertisement

Pet Registration

Pet's Name(Required)
First

Breed:(Required)

Birth Date(Required)
MM slash DD slash YYYY

Pet is a(Required)

Male Dog

Female Dog

Male Cat

Female Cat

Other

Spayed/Neutered?(Required)

Yes

No

Color(s)(Required)

Where did you get your pet?(Required)

Breeder

Pound

Friend

Other

Is your pet on heartworm and/or flea prevention?(Required)

Yes

No

Which ones?

What do you feed your pet?(Required)

Prescription Food

Commercial Food

Table Scraps

Other

How often daily do you feed your pet?

Do you supplement with treats, vitamins, etc?(Required)

Yes

No

Which ones?

Pet is:(Required)

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.

LaCroix Veterinary
Hospital

908 Pine Grove Drive
Wilmington, NC 28409
Call or Text: (910) 799-3100
Email: [email protected]

Hospital Hours
Mon – Fri: 7:30 AM – 5:30 PM
Saturday: 8:00 AM – 12:00 PM
Closed: Sundays

Facebook

Instagram

Copyright 2021 Vets Pets - All Rights Reserved