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New Client Form

"*" indicates required fields

We know you have ample choices when choosing medical care for your pets, and we’re happy that you’ve decided to trust the Family Vet of Lake St. Louis team with your best friends care!

Owner's Information

Have you already scheduled your first appointment by phone or online?*

Yes

Please list the date and time of the appointment*

Owner's First Name*

Owner's Last Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

What phone number did you use to schedule your appointment?*

Is there a co-owner who should be listed on your account?*

Yes

Co-Owner First Name*

Co-Owner Last Name*

Co-Owner's Phone*

Would you like us to call you and schedule an appointment?*

Yes

Owner's First Name*

Owner's Last Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Primary Email*

Primary Phone*

Is there a co-owner who should be listed on your account?*

Yes

Co-Owner's First Name*

Co-Owner's Last Name*

Co-Owner's Phone*

Pet Information

Pet's Name*

Species*

Cat

Dog

Breed*

Color*

Age*

Sex*

Female

Male

Spayed Female

Neutered Male

Has your pet ever had a vaccine reaction?*

Yes

Unknown

Is your pet diabetic?*

Yes

Unknown

Has your pet ever had a seizure?*

Yes

Unknown

What is the reason for your visit?*

Additional Information

Do you have pet insurance?*

Yes

If yes, what pet insurance do you have?*

How did you hear about us?*

Drove by Hospital

Local Rescue or Shelter

Google (or other search engine)

Facebook

Instagram

Referral

If you were referred, please let us know by who*

I consent to Family Vet of Lake St. Louis using my pet's photo and/or information related to its experiences at Family Vet without expectation of pay.*

Yes

Signature*

Phone

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