New Client FormIf you would like to make an appointment, you can expedite your check-in by submitting this form. Thank you for your cooperation in letting us assist you. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Daytime Phone*CellHomeWorkPhone*Secondary care giver and their phone NumberEmail* Pet's Name*Age: Years, Months (If known, or best guess)Type of Pet*CanineFelineAvianExoticOtherSex*MaleFemaleNeutered/Spayed*YesNoWhen was the last time your pet was at the vet? Why?In order to best serve our clients and patients we require records in advance of your appointment. This allows our doctors to review records, and allow them to spend more time with you and your pet in our scheduled appointment time. Please email or fax records 24 -48 hours in advance of your appointment to firstname.lastname@example.org or 708-423-3484. If you do not have your pet’s records please provide us with your previous veterinarian’s contact info and we will call for records.Reasons or conditions that prompted your visit?Briefly describe your pet’s current primary medical problem(s) or the reason for today’s visit. Please note when the problem(s) first started. (if applicable)What medications, supplements or treatment modalities have been used to treat this problem? Have any of these treatments helped? Did any of them make the condition worse? Please list the medications and supplements, including the doses, that you are currently giving. (if applicable)Are there any other chronic (long term) conditions your pet has that we need to know about? (if applicable)Special requests or conditions?Please list any additional pets hereI understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at LePar Animal Hospital and that charges are due and payable at the time of service. Any balance that I leave unpaid will be forwarded to LePar Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.Late appointment policyIn order to best serve our clients and patient we operate on appointments. If you are more than 10 minutes late for a scheduled appointment, we reserve the right to reschedule that appointment. Ideally, we will strive to reschedule that appointment for the same day, with one of our doctors. Depending on scheduled appointments we may need to reschedule for a different day. If an appointment is missed, we will require the next exam be pre-paid prior to scheduling another appointment.I have read this statement and -I agreeI DisagreeNameThis field is for validation purposes and should be left unchanged.