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Welcome to Lansdowne Animal Hospital. Our staff is dedicated to the optimum in patient care and will do its utmost to make your pet’s stay pleasant and beneficial. Please feel free to ask any questions concerning the treatment of your pet or other policies of the hospital. To help us serve you better, please provide us with the following information. All information obtained is confidential and for the purposes of recordkeeping.

Date *

Primary Contact: *

Spouse/Co-Owner Name:

Address: *

City: *

State: *

ZIP: *

Email: *

Best number to reach you by: *

Cell Phone:

Home Phone:

Work Phone:

Place of Employment:

Spouse/Co-Owner Cell Phone:

Spouse/Co-Owner Work Phone:

Spouse/Co-Owner Place of Employment:

How did you choose our practice?

If personal recommendation, whom may we thank?

If event, what event was it?

Patient Information

Pet #1

Name: *

Species:

Breed: *

Date of Birth: *

Sex:

*Spayed/Neutered

Previous Veterinarian: *

Name of the Practice: *

Telephone Number: *

Pet #2

Name: *

Species:

Breed: *

Date of Birth: *

Sex:

*Spayed/Neutered

Previous Veterinarian: *

Name of the Practice: *

Telephone Number: *

Pet #3

Name: *

Species:

Breed: *

Date of Birth: *

Sex:

*Spayed/Neutered

Previous Veterinarian: *

Name of the Practice: *

Telephone Number: *

Any allergies to vaccinations or medications?

At Lansdowne Animal Hospital we abide by doctor/patient confidentiality. As such we would like your permission to communicate appropriate information as the need arises with the following establishments. We are required to divulge Rabies information to Animal Control.

Select all that apply:

Boarding/Grooming FacilitiesAdoption AgenciesNone, contact me if anyone requests information about my petOther Veterinarians

At Lansdowne Animal Hospital we like to show off each patient that comes to visit us on our social media outlets. We use Facebook and other outlets to show how much we care for each patient. Please check each box that applies for you and your patient:

Select all that apply:

May take photos of my pet(s)May take photos of myself the owner(s)May NOT take photos of myself the owner(s)May NOT take photos of my pet(s)

Payment is required at time of service. We accept cash, Visa, MasterCard, and Discover. Thank you.

19393 Promenade Drive
Leesburg, VA 20176
t: 571-333-2247
f: 571-333-2249

BUSINESS HOURS
Mon – Fri 8:00AM to 6:00PM

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