Pet Allergy & Dermatology Specialists

4580 Crackersport Rd
Allentown, PA 18104

(610)391-1200

www.lehighvetderm.com

New Client Check In

We are currently accepting new clients/patients. If you would like to make an appointment, please submit the below form and someone from our office will contact you to schedule. There is currently a long wait (>6 months) for new patients. We do have an active cancellation list and are typically able to get patients in sooner. You can also visit www.acvd.org to find other board certified veterinary dermatologists.

Thank you for your interest in our practice.

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

Reasons or conditions that prompted your visit?

Special requests or conditions?

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties

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