Lakeland Animal Hospital, P.C.
4806 W. Elm Street   McHenry, Illinois  60050  815-385-6925
  
Patient and Client Information Sheet
Thank you for giving Lakeland Animal Hospital the opportunity to care for your pet.
So that we may become better acquainted, please complete the following:

Owner_______________________________________________Phone__________________________
Secondary Owner/Spouse					Phone___________________________
May we text you reminders?   Yes   No  May we post a photo of your pet on Facebook?   Yes   No
Is the pet owner 62 or older?  Yes  No  If you answered yes, please provide birthdate ___________ 
E-Mail___________________________________ Can we sign you up for email reminders?  Yes   No
Social Security #__________________________ Driver’s License Number ________________________

How did you become aware of our hospital?  ______________________________________________
	If recommended by someone please give us their name & phone number so we can thank them! 
Name_____________________________________________Phone______________________

How old was your pet when you acquired it?								
Where did you acquire your pet?    Pet Store      Breeder      Stray/Shelter        Private Owner
	Other	_________________________________________________________

List any prior illness, surgery or drug/vaccination reactions we should know about.																													

Is your pet on a special diet or medication?								
___________________________________________________________________________________

Please request complete medical records from your previous Veterinarian. We can provide you with our fax number or email address for this purpose.

All fees are due upon release of patient.  I accept full responsibility for services rendered, and any charges incurred for nonpayment, including, but not limited to finance/service charges, collection fees, and late fees. There will be a $25.00 fee for any appointments missed or cancelled without giving 24 hour notice. 

Client Signature:  _______________________________________________	  Date:			

Again, thank you for giving us the opportunity to serve you!