NEW CLIENT GENERAL CHECK IN FORM

Prior to you first visit as a New Client

Help us get a jump start on your first visit with us. Please take a moment to fill out and submit this brief questionnaire on you and your pet. By learning about your pet and any concerns you may have, we can more effectively begin working with your family.

* Indicates required field

Name *

First

Last

Primary Phone Number *

Email *

Please note: Your email will be used for Email Reminders, sending Lab Copies, and other clinic correspondence. Your can also access patient information through your Patient Portal.

Spouse or Significant Other Name *

First

Last

Spouse or Significant Other Phone Number *

Street Address *

City, State, Zip *

Work, Occupation, When Available *

Work Phone Number *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

How did you learn of Cliff Lake Veterinary Clinic? *

Pet Name *

Species *

Breed *

Sex *

Birth Date or Age *

Color or Markings *

Name of Previous Clinic *

Previous Medical History *

Fax records to 651-452-2005 or email records to [email protected]

History of Vaccine Reaction? *

History of Seizures? *

Any known Medication Reactions or Allergies? *

Please list current medications or supplements given: *

Please list any past or current medical conditions or surgeries: *

Please describe the reason for your visit and describe all concerns you would like to discuss with the doctor: *

I authorize Cliff Lake Veterinary Clinic (CLVC) to obtain copies of my pets' medical records from my previous clinic(s). I also authorize CLVC to release any pertinent records to grooming, boarding, or other entities contacting CLVC to verify vaccination or medical history. Typing your name below represents your digital signature. *

Thank you for your time, we look forward to seeing you and your pet soon!

Submit

Helpful Info

OFFICE HOURS
Monday 7:30 am - 5:00 pm
Tuesday 7:30 am - 5:00 pm
Wednesday 7:30 am - 5:00 pm
Thursday 7:30 am - 5:00 pm
Friday 7:30 am - 5:00 pm
Saturday call for availability
Sunday Closed

* Note: Doctors on duty starting at 8 am
* Hours subject to change
Check Facebook for Holiday Hours

Get In Touch

CLIFF LAKE VETERINARY CLINIC
1960 Cliff Lake Road, Suite 109
(In Cub Foods mall next to Great Clips)
Eagan, MN 55122
651-452-5156

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NEW CLIENT QUESTIONNAIRE
For SCHEDULED DOCTOR EXAM

Prior to you first visit as a New Client

Helpful Info

CONTACT US & DIRECTIONS

EMERGENCY INFO

Get In Touch

Our Partners In Care

NEW CLIENT QUESTIONNAIRE For SCHEDULED DOCTOR EXAM

Prior to you first visit as a New Client ​

Helpful Info

CONTACT US & DIRECTIONS

EMERGENCY INFO

Get In Touch

Our Partners In Care

NEW CLIENT QUESTIONNAIRE
For SCHEDULED DOCTOR EXAM

Prior to you first visit as a New Client