New Patient Form New Patient Form Have you already scheduled an appointment with us for your new pet?* Yes No PLEASE READ BEFORE CONTINUING: This form is to be information gathering ONLY. You must still call to schedule an appointment with Los Altos Veterinary Clinic. You can do so by contacting our office at (650) 948-8287. Owner InformationOwner Name* First Last Spouse/Secondary Owner Name First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone*Secondary PhoneEmail* Email Consent I consent to receive email alerts about my pet and clinic newsletter.How did you find out about us? Google Yelp Facebook Referral If referred, who may we thank? Social Media & Website Consent* Yes, I give LAVC permission to feature my pet(s) on social media and/or their website. No, I would prefer my pet(s) not be featured on LAVC's social media and/or website. Occasionally, we feature patients on our social media pages and website. Please indicate whether you are comfortable with your pet being featured or not.Pet InformationPet Name* Species* Dog Cat Age or Date of Birth* Breed* Color Do you have records from another veterinarian that need shared with Los Altos Vet Clinic?* Yes No Name and information of clinic for previous records:Upload your pet's previous veterinary records:Max. file size: 64 MB.What are we seeing your pet for (vaccines, check up, spay/neuter, etc.)?* Do you have another pet to provide information for?* Yes No Second Pet InformationPet Name Species Dog Cat Age or Date of Birth Breed Color Do you have records from another veterinarian that need shared with Los Altos Vet Clinic? Yes No Name and information of clinic for previous records:Upload your pet's previous veterinary records:Max. file size: 64 MB.Do you have another pet to provide information for? Yes No Third Pet InformationPet Name Species Dog Cat Age or Date of Birth Breed Color Do you have records from another veterinarian that need shared with Los Altos Vet Clinic? Yes No Name and information of clinic for previous records:Upload your pet's previous veterinary records:Max. file size: 64 MB.Consent to TreatOwner Consent to Treat* As the owner of this pet, I agree to the provisions in this agreement and give Los Altos Veterinary Clinic my consent to treat my animal.At Los Altos Veterinary Clinic our mission is to humanely prolong and improve the relationship between pets and their owners by offering excellent veterinary services in a clean, comfortable and compassionate atmosphere. We reserve the right to refuse service to anyone whose behavior conflicts with our mission. We promise that we will do everything we can to make your pet well, safe and comfortable at all times. While every effort is made to avoid potential issues, adverse reactions can happen to any pet at any time when treatment, medications and/or vaccines are administered. By checking the box, you agree to assume financial responsibility for all services provided to your pet at this office and to not hold the veterinarian and/or staff liable for the care we provide your pet. Payment of fees is due at the time of service. This hospital is not staffed overnight or on the weekends.