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LEBANON SMALL ANIMAL CLINIC, INC.

CLIENT/PATIENT INFORMATION

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICE IS RENDERED. WE ACCEPT CASH, CHECK (WITH ID), AND ALL MAJOR CREDIT CARDS. WE WILL GLADLY PREPARE A WRITTEN ESTIMATE IF YOU DESIRE. PLEASE ASK THE RECEPTIONIST OR DOCTOR.


Today's Date: August 10, 2022

First Owner's Name

First Name*

Last Name*
First Owner's Date of Birth*
I certify that I am 18 years of age or older
First Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
First Owner's Signature*
Second Owner's Name

First Name*

Last Name*
Second Owner's Date of Birth*
Second Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Third Owner's Name

First Name*

Last Name*
Third Owner's Date of Birth*
Third Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Fourth Owner's Name

First Name*

Last Name*
Fourth Owner's Date of Birth*
Fourth Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Fifth Owner's Name

First Name*

Last Name*
Fifth Owner's Date of Birth*
Fifth Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Sixth Owner's Name

First Name*

Last Name*
Sixth Owner's Date of Birth*
Sixth Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Seventh Owner's Name

First Name*

Last Name*
Seventh Owner's Date of Birth*
Seventh Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Eighth Owner's Name

First Name*

Last Name*
Eighth Owner's Date of Birth*
Eighth Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Ninth Owner's Name

First Name*

Last Name*
Ninth Owner's Date of Birth*
Ninth Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Tenth Owner's Name

First Name*

Last Name*
Tenth Owner's Date of Birth*
Tenth Owner's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Spouse/Other:

Home Telephone:

Cell Phone:

Address:

City, State:

Zip Code:

Current Employer:

Work Telephone:

Alternate individual authorized to present pet for treatment:

Their Phone Number:
How did you first hear of our clinic?*

If Referral, who is someone we may thank?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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