Lakemont Village Veterinary Hospital

Phone: 425-641-8733

Fax: 425-458-9639

4935 Lakemont Blvd. SE
Bellevue, WA 98006

(425)641-8733

www.lakemontvillagevet.com

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

Name *(required)*

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

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Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
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E-Mail Address :

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary Practice?

Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?

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Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

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