New Clients

Welcome!

Leesville Animal Hospital wants to be your pet's choice for total animal care! In order to provide you with the best our team has to offer, please complete our new client registration form. If you would rather print out this form and bring it with you to our clinic you can download this form here. 

If you are unable to view this form please download the Adobe Acrobat Reader

We thank you for giving us the opportunity to care for your pets!

Owner's Name (required)

Owner's Address (required)

Home Phone (required)

Cell Phone (required)

Work Phone (required)

E-mail Address (required)

Significant Other/Co-Owner Name (required)

Significant Other/Co-owner Phone (required)

Additional Emergency Contact Name (required)

Additional Emergency Contact (required)

Authorized person(s) to pick up your pet(s) in your absence (required)

Previous Veterinarian (required)

Please complete the following information for pets 1-3.


Pet 1

Pet's Name (required)

Cat or Dog (required)

Pet's Breed (required)

Pet's Sex (required)

Spayed or Neutered (required)

Pet's Age (required)

Pet's Date of Birth if Known, if unknown leave blank

Indoor or Outdoor Pet (required)

Current Medications (required)

Pet 2

Pet's Name

Cat or Dog

Pet's Breed

Pet's Sex

Spayed or Neutered

Pet's Age

Pet's Date of Birth if Known, if unknown leave blank

Indoor or Outdoor Pet

Current Medications

Pet 3

Pet's Name

Cat or Dog

Pet's Breed

Pet's Sex

Spayed or Neutered

Pet's Age

Pet's Date of Birth if Known, if unknown leave blank

Indoor or Outdoor Pet

Current Medications

Additional pets may be listed in the text box below.

Other Pet's Information


By providing my digital signature on this online form, I understand that I am providing my authorization for the veterinarian(s) to examine, prescribe for and treat my pet(s) and I assume financial responsibility for all charges incurred on behalf of my pet(s). I understand that payment is expected at the time that services are rendered and a deposit may be required before any treatment begins.


I certify that I have read and agree to the terms outlined above.


Your Name (required): Digital Signature (required): Date (required):

Hours & Contact Information
X

Our Hours

Monday: 7:30 a.m. - 5:30 p.m.
Tuesday: 7:30 a.m. - 7 p.m.
Wednesday: 7:30 a.m. - 5:30 p.m.
Thursday: 7:30 a.m. - 7 p.m.
Friday: 7:30 a.m. - 5:30 p.m.
Saturday: 9 a.m. - 2 p.m.
Sunday: Boarding pick up 5 - 6 p.m.

 

Call Us: (919) 870-7000

 

Visit Us: 9309 Leesville Rd,
                 Raleigh, N.C. 27613
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