Great Lakes Veterinary Behavior Consultants

45298 Indian Creek Drive
Canton, MI 48187

(734)454-7470

www.greatlakesvetbehavior.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 cooperation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
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Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
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E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)

Male
Female


Neutered/Spayed

Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?

Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?

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Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here


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