Lone Mountain Animal Hospital
We Welcome New Clients
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Lone Mountain Animal Hospital receives new clients and patients to its facility everyday and appreciates referrals.  If it is your first visit to the hospital, you will asked to complete a new client form on-site when you arrive for your pet's appointment.  Please bring records that you have kept of your pet's medical history. e.g. most recent vaccination dates and any treatment history.  We also welcome you to stop by the clinic at your convenience during our normal business hours to pick-up a form in-person and to make your appointment at that time.

1) You may download an Adobe PDF file of our registration form to complete before your visit - Click Here
(PC users, right-click to download/save, left-click to view through browser; Mac users, control-click to download)

2) You can get a browser-printable form (2 pages) to also complete at your leisure to bring with you - Click Here

3) You can also submit your information online:

We've enabled this online pre-registration feature for new clients.  Note that use of this feature does not schedule an appointment.  Please allow up to 3 days for processing of this online application before your anticipated visit which will, in turn, be processed immediately following confirmation by telephone and the scheduling of your appointment by one of our receptionists.  To pre-register an account with us, you may complete and submit the form below.  You will need to have your pet's vaccination records and medical history handy.

These options will assist us in expediting your first visit!  We looks forward to meeting you and your pet(s)!

Please use the TAB key or your mouse to move between fields, not the "ENTER" key. "ENTER" will submit this form prematurely.

 Personal Information 

Owner's First Name

 Last name   Social Security No. *
 
Spouse/Other Last Name   Social Security No. *
 
 * Optional, e.g. 123-45-6789 -  If not provided, cash or credit card only; no checks
 
Drivers License Number:		  
Issuing State: 		 
Expiration:
  
Street Address/P.O. Box
  
Unit/Apt.
City, State, Zip+4:

 
Home Phone:

Work Phone:

Cell Phone:

E-mail Address:

Do you wish to receive our monthly e-mail newsletter?  Yes     No

Employer:

Employer Address:

City, State, Zip+4:
In case of emergency, call (name) at (number)


 How did you hear about our hospital?  (check all that apply)

Hospital Sign     Yellow Pages     American Animal Hospital Association

Animal Foundation     Dewey Animal Shelter

Individual - Someone we may thank:

Other - Please specify:

 Previous animal hospital/veterinarian information 

Name of clinic or doctor:
                    City/State:

May we request your pet's health records?  Yes     No

 Animal Medical History  (complete one column for each pet, as completely as possible)

Pet Information

1st Pet

 2nd Pet

3rd Pet

Name:

Species (dog, cat, reptile, bird, etc.):

Breed:

Description/Color(s):

Date of Birth:

Sex:
(Female, Male,
Female/Spayed,
Male/Neutered)
F
F/S
M
M/N
F
F/S
M
M/N
F
F/S
M
M/N

Length of time owned:

Diet (type of pet food):

Please provide dates of most recent shots (mm/dd/yy)

Vaccination History

 1st Pet 2nd Pet 3rd Pet
Dogs

Distemper:

Rabies:

Parvo Virus:

Corona Virus:

Bordatella:
(kennel cough)

Lyme:
Cats

ENT-FVRC
(Feline Distemper)

Rabies

FeLV
(Feline Leukemia)

FIP
(Feline Infectious Peritonitis)

Previous Medical History

Pet 1

Pet 2

Pet 3
Current Special Diet?
Currently on Medication?  Type?
Prior Illness?
Prior Surgery?
Prior Urinary Problem?

Any other information you feel we should know about your pet?

ALL FEES ARE DUE AT THE TIME THE PATIENT IS RELEASED
Upon your request, we will be happy to provide you with a written estimate of fees for any treatment,
emergency care, surgery, or hospitalization.  A deposit may be required prior to some procedures/treatment.

Submitting this electronic form indicates your intent to secure the services of Lone Mountain Animal
Hospital and for us to proceed with the creation of an account for you in our system.  Lone Mountain
Animal Hospital is not responsible in the unlikely occurrence of a technical error when submitting this
form, errors or misinformation entered by the submitter, and other circumstances beyond the hospital's
control.  All personal information submitted is confidential and for internal use according to hospital
policies and to the extent allowed by applicable government, consumer, and financial regulations.

I have read the notice above and accept these terms

I do not accept this the terms of this notice - take me back to the Main Page (your entries will not be saved)

If you have filled-in the fields above as completely as possible, click the "Submit" button below.
(just once, please -- it may take a few seconds to process)

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