New Patient Information Form

Date

Owner's Name

Owner’s Date of Birth (For purposes of dispensing medication as required by law for certain prescriptions)

Address

City/State

Zip Code​​​​​​​

Home Phone

Cell Phone​​​​​​​

Email

Employer​​​​​​​

Work Phone​​​​​​​

Co-Owner’s Name

Co-Owner Phone​​​​​​​

How did you hear about us?

Referred by: (Whom may we thank for referring you?)​​​​​​​

Animal Name

Birth Date​​​​​​​

Species:​​​​​​​

Environment

Breed

Color/Description

Hair​​​​​​​

Sex

Is your pet neutered?

When and where did a veterinarian last see your pet and what was the purpose of visit?​​​​​​​

Has your pet had any serious illnesses or injuries?​​​​​​​

Does this animal have any known drug sensitivities?​​​​​​​

Please list any other pertinent information concerning your pet’s health history​​​​​​​

Please list other pets in your household (Type and age of animal).​​​​​​​

By checking this box, I allow La Jolla Vet to use my pet's name and photo on social media accounts for promotional purposes.

Please be advised that we do not do allow any billing unless specific arrangements have been made in advance. In those cases, a monthly billing fee and interest charge will be added to the balance due. *Balance is due at the time services are rendered.

Owner E-Signature