New Patient Form

Thank you for choosing Lucks Lane Veterinary Clinic. Please complete this form after scheduling your appointment with our Front Desk Team.

(804) 594-3545

Date of Appointment

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Client Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

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Home Phone

(###)

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Work Phone

(###)

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Pet's Name

Species

Sex of Pet

Spayed / Neutered?

Yes

Unknown

Age

Breed

Breed of pet. If unknown, please leave blank.

Color

Social Media

I give permission for Lucks Lane Veterinary Clinic to use my pet's picture and name on our social media sites, website, or any advertising materials.

Yes

TERMS & CONDITIONS

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED JOINTLY AND SEVERALLY GUARANTEE PAYMENT. I AGREE TO REIMBURSE LUCKS LANE VETERINARY CLINIC THE FEES OF ANY COLLECTION AGENCY, WHICH MAY BE BASED ON A PERCENTAGE AT A MAXIMUM OF 32% OF THE DEBT, AND ALL COSTS AND EXPENSES INCLUDING ATTORNEY FEES IN SUCH COLLECTION EFFORTS. PAYMENT OF ALL FEES IS REQUIRED AS SERVICES ARE RENDERED. THERE WILL BE A $30.00 SERVICE CHARGE FOR ANY AND ALL RETURNED CHECKS. By typing your name below, you agree that you have read this form and are aware of the above payment policy. You agree that typing your name below is an acceptable form of signature.

Date