Site Accessibility Features: Skip to page menus 
 
Reset Website AccessibilityIncrease Font SizeDecrease Font Size

 Site Menus Section  Skip to page content 
    


 
Home
 
Patient Center 
 
New Pet Form
 
About Us 
 
Team
 
Payment Options
 
Services 
 
Medical Services
 
Additional Services
 
Anesthesia and Patient Monitoring
 
Wellness and Vaccination Programs
 
Preventive Services
 
Surgical Services
 
Exotic Pet Medicine and Surgery
 
Health Screening Tests
 
Pet Health 
 
Pet Health Library
 
How-To Videos
 
Pet Health Checker
 
Pet Food Recalls
 
Pet Insurance
 
Product Recalls
 
News
 
Contact Us
 
Online Pharmacy
 
facebookgoogle-plus
 

 

New Pet Form



Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.



Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s).  The required sections have a red * asterisk.

Owner's Name
Name*



First



Last


Address*



Street Address


Address Line 2


City


State / Province / Region


ZIP / Postal Code

AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
Country


Day-Time Phone*
Evening Phone
Mobile Phone
Email*



Enter Email



Confirm Email


Co-owner's Name & Contact #
Name



First



Last


Phone
How did you find out about our practice?
Clinic Location
Personal Referral
Internet Search / Website
Yellow Pages
Clinic Sign
Newspaper / Print Media
Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information
Pet's Name*
Species*
DogCatRabbitFerretBirdReptile
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Neutered MaleSpayed FemaleMaleFemaleUnknown
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)


Date Format: MM slash DD slash YYYY

What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Would you like to add another pet?*
Yes
No
Second Pet Information
Pet's Name*
Species*
DogCatRabbitFerretBirdReptile
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Neutered MaleSpayed FemaleMaleFemaleUnknown
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)


Date Format: MM slash DD slash YYYY

What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet


 












Δ


Contact
220 S Catherine St

Montour Falls, NY 14865
 
Phone: (607) 535-2500

Fax: (607) 535-8037
Hours
Monday: 8:00 am-5:00 pm

Tuesday: 10:00 am-6:00 pm

Wednesday: 8:00 am-5:00 pm

Thursday: 10:00 am-5:00 pm

Friday: 8:00 am-5:00 pm

Saturday: 9:00 am-12:00 pm

Sunday: Closed
After Hours/Emergencies
Cornell Companion Animal Hospital

Phone: 607-253-3060

(For emergencies press 1)

Save Time, Shop Online
Online Pharmacy 

 © 2025 Lakeside Veterinary Services.

Powered by LifeLearn Veterinary Websites