Larchmont Village Vet - New Client Information Form

Primary Contact Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Email

example@example.com

Primary Contact Date of Birth

Date

Secondary Contact's Name

First NameLast Name

Secondary Contact's Email

example@example.com

Primary Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about us?

Friend or Family Member Referral

Previous Animal Hospital

Pet's Name

Species

Breed & Color

Sex

Age/Birthday

Pet Microchip Number If Applicable

Pet Insurance Company and Policy Number If Applicable

Any Previous Adverse Reactions? (Vaccine, Medication, etc.)

List Any Behavior Concerns We Need To Be Aware Of

Additional Pet's Name

Additional Pet Species

Additional Pet Breed & Color

Additional Pet Sex

Additional Pet Age/Birthday

Additional Pet Microchip Number

If Applicable

Additional Pet Insurance Company and Policy Number If Applicable

Additional Pet Previous Adverse Reactions? (Vaccine, Medication, etc.)

Additional Pet Behavior Concerns We Need To Be Aware Of

Pet/Owner Instagram Account(s)

Upload any previous medical records prior to your visit.

Appointment Cancellation & Late Arrival Policy

We understand that schedules can change. If you need to cancel or reschedule your appointment, please notify us as soon as possible so we can offer that appointment time to another pet in need of care.

Doctor appointments that are missed without prior notice ("no-shows") will require a deposit before scheduling a future appointment.

Surgery/Ultrasound/Dental Cleaning appointments require at least 48 hours' notice for cancellation or rescheduling. Cancellations made with less than 48 hours' notice may result in forfeiture of the appointment deposit.

To help keep doctor appointments running on time, we offer a 15-minute grace period for late arrivals. Clients arriving more than 15 minutes after their scheduled appointment time may be asked to reschedule their visit or wait for the next available opening, depending on the doctor's schedule.

Thank you for your understanding and cooperation.

Pet Information

Additional Pet Information