IHE Owner Form

IHE Client / Patient Form

First Name

Last Name

Name - Spouse / Partner / Co-Owner

Mobile Phone (for call and text)

Street Address

Street Address Line 2

City

State

Postal / Zip code

Birthday (must be 18 years or older) required

Driver's License number

Contact/confirmation preference - Phone / Text / E-mail (can choose more than one option) Required

Please confirm by Phone

Please confirm by Text message

Please confirm by E-mail

What services are you requesting? Briefly describe the needs of your pets. **NO emergency or surgery services**

Does anyone (human or animal) in your home have any allergies that we should be aware of? For example, peanut butter?

Where did you hear about us? Referral, Google, Yelp? If referral, please let us know who

I agree to the terms & conditionsView terms of use

I have read and agree to Dr. Lola's Veterinary Care Policies View Policies

Name(s) of Patient(s)

Species of Patient: (Dog or Cat)

Sex of Patient - let us know if spayed/neutered:

Age or DOB of Patient:

Breed of Patient:

Coat Color of Patient:

Weight (approximate):

Microchip # (if has one)

Please share any previous medical history about your pet - vaccine history? Any previously diagnosed illnesses? Are they on medications?

Please let us know if you pet is still eating/drinking? Are they still moving around comfortably?

Does your pet have a regular Veterinarian? (if they do, let us know who)

Has your pet ever bitten anyone?

What are your aftercare wishes? Communal cremation / Private cremation / Home Burial

Would you like a complimentary commemorative clay paw print?

If your pet is large, is there someone in the home who can help our veterinarian carry the pet to the vehicle? Required

Yes

(Please make sure to click the button to Submit your information!)

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