Online Patient Registration Form

Making Patient Registration Easier! (printable form also available here)

Full Name:	*
Address:	*
City:	*
State:	*
Zip:	*
Home Phone:	*
Work Phone:
Cell Phone:
Email:
Spouse or Co-Owner:
Referred by:

Patient Information

Pet's Name:

*

Sex:

select male female *

Altered:

select yes no *

Age or Birthdate:		Breed:
Microchip #:		Color:

Species: Canine, Feline or other:

*

Reason for Visit:
How did you hear about us?

LSAH requires that Rabies and Distemper vaccines be "up-to-date" on all patients staying in the hospital. If we find any signs of fleas on any hospitalized pet, we will apply a topical flea preventative to your pet at an additional cost to the client. We ask that all cats be contained safely inside of a carrier or "breathable" box, and all dogs be on a leash.

Payment is due at the time of service. We accept all major credit cards, Care Credit, and cash. Unfortunately we no longer accept personal checks. The client agrees that any amount unpaid after 30 days will be subject to interest at the rate of 2.5% per month (or 30% per year) until such unpaid amount is paid in full as well as monthly statement and handling fees. Additionally, the client will be responsible for the reasonable costs of collection of any such unpaid amounts, including collection and attorney fees. Thank you.
 

Validation Please insert the letters and numbers exactly as you see them in the image on the right. This has been included to eliminate "bots" from filling in this form.

*