Welcome to Lamington Terrace Veterinary Surgery. We aim to give you and your pet the best possible service and care. Please assist us by completing this questionnaire to ensure we have your correct details.

All fees are payable in full at time of consultation or discharge of animal from hospital.

We accept Cash, Visa, Mastercard and Eftpos

Once again, Welcome and thank you for giving us the opportunity to play a part in caring for your pet!

NB: You can also print out this form and bring it with you!

Your Contact Details

Title: *

Name: *

Address: *

Email Address: *

Preferred Contact Telephone: *

Mobile Telephone:

Home / Work Telephone:

Notification Methods

Patient Reminders ie vaccinations:

Email

SMS

Phone Call

Post

Appointment Reminders:

Email

SMS

Phone Call

Newsletters:

Email as attachment

Email with link to website

Post

Tell Us About Your Pets

Pet #1

Pet's Name: *

Date Of Birth: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

Breed: *

Colour:

Sex: *

Male

Female

Desexed: *

Yes

No

Pet Insurance Name & Number:

Vaccination Date:

Leave blank if your pet is not vaccinated

Heartworm Prevention Type:

Leave blank if you pet has no prevention method

Microchip Number:

Leave blank if pet is not microchipped

Flea / Tick Control Type:

Leave blank if pet has no flea or tick control method

Are there any other previous medical issues/concerns that might affect your pet’s care?:

Pet #2

Pet's Name:

Date Of Birth:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

Breed:

Colour:

Sex:

Male

Female

Desexed:

Yes

No

Pet Insurance Name & Number:

Vaccination Date:

Leave blank if your pet is not vaccinated

Heartworm Prevention Type:

Leave blank if you pet has no prevention method

Microchip Number:

Leave blank if pet is not microchipped

Flea / Tick Control Type:

Leave blank if pet has no flea or tick control method

Are there any other previous medical issues/concerns that might affect your pet’s care?:

Pet #3

Pet's Name:

Date Of Birth:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

Breed:

Colour:

Sex:

Male

Female

Desexed:

Yes

No

Pet Insurance Name & Number:

Vaccination Date:

Leave blank if your pet is not vaccinated

Heartworm Prevention Type:

Leave blank if you pet has no prevention method

Microchip Number:

Leave blank if pet is not microchipped

Flea / Tick Control Type:

Leave blank if pet has no flea or tick control method

Are there any other previous medical issues/concerns that might affect your pet’s care?:

General Questions

How did you find our practice?: *

Yellow Pages

Drive by

Our website

Referred by friend or family

Other

If a friend or family member referred you to us, please tell us their name so we can thank them! :

Enter code above: *