New Patient Registration Form

Laguna Beach Veterinary Medical Center

Owner/Pet Registration Form

"*" indicates required fields

Date

Client Information

Owner's Last Name*

Owner's First Name*

Address*

City*

State*

Zip Code*

Primary Phone #

Secondary Phone #

Email Address*

Driver's License #

DOB

(In Order to Dispense controlled medications)

Secondary Owner's Name

Secondary Owner's Phone #

Patient Information

Pet's Name

DOB or Age

Sex

Male

Female

Spayed/Neutered

Yes

Species*

Breed

Color

Any known allergies (food or medications)

How did you hear about Laguna Beach Veterinary Medical Center?

**If a friend referred you, whom can we thank?

Additional Permissions

Do we have your permission to post pictures of your pet(s) on our social media?

Yes

Do we have your permission to send medical record to other facilities upon request (i.e, hospitals, boarding, insurance, groomers, etc.)?

Yes

Appointments

Our veterinary services utilize veterinary scribe and automatic note-taker to record your pet’s appointments for improved clinical records. By signing this you agree that your vet appointments may be recorded. If you don’t want to be recorded, please let us know.

Comments

This field is for validation purposes and should be left unchanged.

New Patient Registration Form

Laguna Beach Veterinary Medical Center

Owner/Pet Registration Form

Client Information

Patient Information

How did you hear about Laguna Beach Veterinary Medical Center?

Additional Permissions

Appointments

Address

Call Us

Operating Hours

Email Us

Services

About

Our Location