New Client Registration

Owner's Name*

First Last

Owner's DOB

Co-Owner's Name

First Last

Address*

Street Address Address Line 2 City ZIP / Postal Code

Primary Phone*

Primary Phone Description*

Secondary Phone Number

Secondary Phone Description

Primary work phone

Email Address

How did you hear about our hospital?*

Are you interested in Integrative medicine(acupuncture, etc)?

Is there someone we can thank?

Pet's information

Name*

Species*

Dog
Cat

Breed*

Date of birth

Color/Description*

Gender*

Male
Female

Spayed/Neutered*

Yes
No

Previous clinic information(Name & City)

Allergies to vaccines or any known allergens?

Current Medications or Ailments?

Previous illnesses or surgeries?

Second Pet's Information

Pet's Name

Species

Dog
Cat

Breed

Date of birth

Color/description

Gender

Male
Female

Spayed/Neutered?

Yes
No

Allergies to vaccines or any known allergens?

Current Medications or Ailments?

Previous illnesses or surgeries?

Payment is required at the time of service.

We accept cash, checks, VISA, MasterCard, Discover, American Express and CareCredit.

I authorize the staff of LGD&CH to render any treatment which is deemed necessary to my pet’s health. I understand that the staff will make every attempt to contact me in an emergency situation, time permitting, and I will be financially responsible.

May we post pictures of your pet(s) on our website or Facebook?

Yes
No

We do not release any of the owner's information when posting pictures, the only information released is the patient's name, breed and age.

By choosing yes below I agree to the terms stated above.*

Yes
No

If you have already scheduled an appointment, please fill in the appropriate date below.

If you haven't scheduled an appointment yet please call us at (408) 354-6474.

Monday	8:00am – 8:00pm
Tuesday	8:00am – 8:00pm
Wednesday	8:00am – 8:00pm
Thursday	8:00am – 8:00pm
Friday	8:00am – 8:00pm
Saturday	8:00am – 5:00pm
Sunday	Closed

Contact Us

New Client/Patient Form

Pet's information

Second Pet's Information

Resources

New Client Registration

New Client/Patient Form

Pet's information

Second Pet's Information

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Resources