New Client Registration

Welcome to Lafayette Veterinary Care Center. So we may provide you with exceptional service, please share information about you and your pet(s).

Client Information

Client Name:

Spouse's Name:

Address:

City: State: Zip:

Home Phone:

Mobile Phone:

Alt Phone:



Employment Information

Employer's Name & Telephone:

Spouse's Employer & Telephone:



General Information

Who may we contact in the event of an emergency if you are unavailable?

Name: Phone:

Relationship:



How did you become familiar with our hospital?

Another Client:

SignWebsiteGooglePrint AdGroomerFacebookYellow PagesTV AdCommunity EventMail AdAngie's LisFamily Adventure DayOther


Patient Information

1. Pet's Name:

Age/Birth Date:

Sex:

Spayed/Neutered: Microchipped:

Species: Breed:

Color: Weight:



2. Pet's Name:

Age/Birth Date:

Sex: Spayed/Neutered: Microchipped:

Species: Breed:

Color: Weight:



If your pet is coming to us from another veterinarian, may we collect previous records?

Previous veterinary care by:



Please be aware that we now offer formal estimates or treatment plans for all services by request. Please ask our staff if you would like to be provided a treatment plan outlining the cost of your pet?s care at any time. A deposit may be required for surgery or hospitalization upon admittance. Full payment is due upon the conclusion of care for each in?patient and out?patient services.  



Please indicate your primary choice of payment:





Valid E-mail Address:



How would you like to receive reminders and health updates from us?

Post-CardE-mail



We routinely take pictures of our pet patients for their records and occasionally share these on our company websites. May we share your pets photo in these materials?

YesNo


Lafayette Veterinary Care Center
Lafayette Veterinary Care Center