Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

You will be asked to select a password, which must be at least 4 characters in length. Ensure this is something you will easily remember. This password will be needed to access client only areas of our site.

Client Information

Owner´s Name

Salutation

*First Name:

*Last Name:

*New Password:

*Confirm Password:

Co-owner´s Name:

Salutation:

First Name:

Last Name:

Address

*Country:

*State/Province:

*City/Town:

*Address 1:

Address 2:

*Zip/Postal Code:

*Day-Time Phone:

( ) -

*Evening Phone:

( ) -

Mobile Phone:

( ) -

*E-Mail:

*Confirm E-Mail:

Co-Owner´s Contact Information

Day-Time Phone:

( ) -

How did you find out about our practice?

Clinic Location	Website	Yellow Pages
Clinic Sign	Newspaper	Personal Referral
Other

If Other, Please Specify:

If Personal Referral, is there Someone we can Thank for this Referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

*Pet´s Name:

*Species:

or if other species:

Breed (If Known):

Color:

Date of Birth:

Special Identification
(Tattoo, Microchip, etc):

Sex:

Previous Veterinary Practice (If Any):

Previous Veterinarian (If Any):

Date of Last Vaccines (if known, yyyy/mm/dd)

What Vaccines were given at this Time:

Is your Pet on any Medication or Supplement?

	Yes
	No

If Yes, Please List the Medication or Supplement:

What food does your pet eat?

Please type answer here:

Does your Pet have Allergies or Drug Reactions?

	Yes
	No

If Yes, Please List the Allergies and reactions:

Are there any Current or Past Medical Conditions of which we should be Aware?

	Yes
	No

If Yes, Please Comment on the Condition(s) and Indicate if they are Current or Past Conditions:

Please use the following box to give us any other relevant information about your pet:

Please enter the validation code to the right to complete registration.	[javascript must be enabled]

September 4, 2010

Five signs that your animal might be in pain
(Sep-01-2010)
Rabies as a human health threat
(Sep-01-2010)

Coggins (EIA) Now available on line (8-1-2010)
Laser Therapy Now Available (8-1-2010)
Name Change (8-1-2010)
Third Clinic (2-25-2010)
Expansion of Western Hills Clinic (12-24-2009)

more...

Lakeview Veterinary Clinic, PC
17156 West F.M. 1097, Suite 12
Montgomery, Texas 77356
Phone: (936) 597-6039
Fax: (936) 597-6041
Serving Willis and surrounding areas.

Western Hills Animal Medical & Surgical Clinic
19380 Hwy 105 W. Ste. 514
Montgomery, TX 77356
Phone: (936) 582-4223
Fax: (936) 582-4230
Serving Montgomery and surrounding areas.

Lake Way Animal Medical & Surgical Clinic
9521 W FM 1097 Suite B
Willis, Texas 77378
936-856-0200
(Opening Fall 2010)
Serving Willis, and Surrounding Areas

Check out the links to our new online pharmacy!

Western Hills Clients Click Here

Lakeview Clients Click Here