228-207-6864 [email protected]

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Save time, complete your New Client Form online!

Please complete the form below and a member of our team will get back to you as quickly as possible if we have any questions. If this is an emergency situation, please call us at 228-207-6864.

Name of Pet Owner *

First

Last

Email *

Home Phone *

Cell Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Owner

First

Last

Phone

Please select your preferred method(s) of notification for reminders. *

Phone
Email
Text Message

How did you become aware of our clinic? *

Drove By
Yellow Pages
Website
Social Media
Previous Client
Other

If other, please explain.

Who may we thank for the referral? *

Would you allow us to feature your pet in social media (last name will be omitted)? *

Yes
No

Pet's Name *

Species *

Canine
Feline

Breed *

Age or Birthday *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Vaccination History (date and type of last vaccinations)

Please check (✓) any symptoms or problems that you have noticed about your pet:

Behavior Problems
Breathing Problems
Coughing
Diarrhea
Eye Bulging or Bloodshot
Gagging
Lack of/Decreased Appetite
Limping
Loss of Balance
Scooting
Scratching
Seems Depressed
Shaking Head
Sneezing
Thirst and/or Urination Increase
Vomiting
Weakness
Other

If Other, please explain.

Previous veterinarian(s)/Hospital(s)

Authorization to obtain medical records:

Yes, full medical history
Yes, vaccination history only
No, not at this time

Current medications:

Pet’s allergies (food, seasonal, medication, etc):

Current diet:

No show appointments will require a $50 non-refundable deposit prior to scheduling future appointments *

I have read and understand.

Professional fees are to be paid at the time services are rendered. *

I have read and understand.

Please indicate choice of payment (Lakeview Animal Hospital does not accept checks as a form of payment):

Cash
Debit
Visa
MasterCard
Discover
CareCredit

I am responsible and agree to pay in full the total charges for services rendered at the time of discharge and any fees incurred for the collection of said charges. I understand that the fees are based on treatment deemed necessary at the time of the exam, treatment or admission and that the estimate fee may be raised or lowered by the administration of treatment, medication, surgery, or diagnostic testing. *

I have read and understand.

Digital Signature *

Today's Date *

Email

Welcome to Lakeview Animal Hospital!

We proudly serve the pets of D'Iberville, Ocean Springs, Vancleave, Biloxi, St. Martin, Woolmarket, Latimer, and Gulfport.

Contact Us

Phone: 228-207-6864
Fax: 228-207-7119
Email: [email protected]

Visit Us

11505 Cinema Dr. Suite #12
D'Iberville, MS 39540
Click here for directions.

Hours

Mon - Fri: 8:00 am - 5:00 pm
Sat: 8:00 am - 12:00 pm
Sun: Closed

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