Welcome to East Lake Veterinary Hospital!

We are glad you have chosen us for your pet(s) health and / or grooming needs. We are committed to providing excellent pet health care with exceptional customer service. Please take a few minutes to tell us about yourself and your pet(s) so we may get better acquainted. Thank you!

Filling out this form does not constitute making an appointment! If no appointment is scheduled, please call us at 214-342-3100, so we can schedule you.

Why did you choose East Lake Veterinary Hospital. Check as many boxes as apply.

Referral. Who? So we may thank them
Yellow Pages
Neighborhood Newsletter
Housewarmers (Lake Highlands)
Housewarmers (Park Cities)
Newspaper Ad
Our website (welovepets.net)
Google Advertisment
Doggeek.com
East Lake Pet Orphanage
Other website
Other hospital referral. Which hospital?
Shelter Referral. Which shelter?

Date of your appointment:
Who is your appointment with
What is your appointment for

Pet Guardian : Co-Guardian
Street Address:
City: State: Zip:
Employer: Occupation:
Guardian's Date of BIrth: Co-guardian's Date of BIrth:

Co-Guardian Address if different than above:
e-mail address: Co-Guardian e-mail:
Home phone: Work Phone: Other
Co-Guardian phone: Work Phone: Other

Co-Guardian Employer: Co-Guardian Occupation:
Driver's License: State: Social Security Number:
Co-Guardian's License: State: Social Security Number:

I authorize East Lake Veterinary Hospital to obtain/release all medical records pertaining to my pet(s) to other hospitals, boarding facilities, or grooming facilities.

I do not authorize East Lake Veterinary Hospital to obtain/release all medical records pertaining to my pet(s) to other hospitals, boarding facilities, or grooming facilities.

I understand that I am financially responsible for any services or products provided, and that payment is due in full at the time services are rendered.

Name: Date:

Pet Information:

Pet's name Breed Color Date of Birth

Male Female Spayed Neutered Intact Unknown

Where did you acquire this pet?
How long have you owned this pet? Most recent vet or clinic:
Date of last physical exam: Date of last vaccination:
Describe any existing medical conditions:
List any medications or diet:


Pet's name Breed Color Date of Birth

Male Female Spayed Neutered Intact Unknown

Where did you acquire this pet?
How long have you owned this pet? Most recent vet or clinic:
Date of last physical exam: Date of last vaccination:
Describe any existing medical conditions:
List any medications or diet:


Pet's name Breed Color Date of Birth

Male Female Spayed Neutered Intact Unknown

Where did you acquire this pet?
How long have you owned this pet? Most recent vet or clinic:
Date of last physical exam: Date of last vaccination:
Describe any existing medical conditions:
List any medications or diet:

Pet's name Breed Color Date of Birth

Male Female Spayed Neutered Intact Unknown

Where did you acquire this pet?
How long have you owned this pet? Most recent vet or clinic:
Date of last physical exam: Date of last vaccination:
Describe any existing medical conditions:
List any medications or diet:

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