Lehigh Valley Veterinary Dermatology

4580 Crackersport Rd
Allentown, PA 18104

(610)391-1200

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 TypePhone Number (required)
Evening Phone (required)
Phone TypePhone 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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