Registration Form

If you wish to pre-register your pet with Lance Animal Hospital prior to its first appointment, please fill out the new patient registration form.

Your First Name (required)

Your Last Name (required)

Your Email (required)

Your Address

Your Home Phone

Your Cell Phone

Your Employer

Your Work Phone

Your Spouse's Name

Your Spouse's Phone Number

Emergency Contact

Emergency Contact Phone Number

How did you hear about us?

Who recommended you?

Pet #1 Information

Name

Species

Breed

Color

Age

Sex

Birthday

Weight

Altered

Micro-Chip Number

Does your pet have any allergies? if so please list:

Has your pet had any vaccinations in the past year? If so what and when:

Other Information

Pet #2 Information

Name

Species

Breed

Color

Age

Sex

Birthday

Weight

Altered

Micro-Chip Number

Does your pet have any allergies? if so please list:

Has your pet had any vaccinations in the past year? If so what and when:

Other Information

Pet #3 Information

Name

Species

Breed

Color

Age

Sex

Birthday

Weight

Altered

Micro-Chip Number

Does your pet have any allergies? if so please list:

Has your pet had any vaccinations in the past year? If so what and when:

Other Information