New Client

Lehigh Valley Veterinary Dermatology

4580 Crackersport Rd
Allentown, PA 18104

(610)391-1200

www.lehighvetderm.com

New Client Check In

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 cooporation in letting us assist you.

New Client

Name & Email (required)

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

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

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Pet's Name (required)

Date of Birth

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pets vaccines current?

Do you have a copy of your pets medical records?

Name of Regular Veterinarian (include name of doctor and hospital)

Would you like us to call you for your appointment

Please indicate your time/date preference for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

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