Mon – Fri: 8 AM – 6 PM
Sat: Hours vary. Please call before stopping in.

Sunday Closed

952-423-6800

5049 Upper 141st Street West

Apple Valley MN 55124

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Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone*

Evening Phone*

Email*

Pet's Name*

Age: Years, Months

Type of Pet*

Breed*

Fur Color of Pet

Sex*

Male

Female

Neutered/Spayed

Neutered

Spayed

Neither

Are your pets vaccines current?

Yes

No

Do you have your pets medical records?

Yes

No

May we request a transfer of records>?

Yes

No

Name of former Veterinary Practice

Medical records at another veterinary practice?

Yes

No

Would you like us to call you for your appointment?

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Reasons of conditions that prompted your visit?

Please list any additional pets here

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Address:

5049 Upper 141st Street West
Apple Valley MN 55124

Email: eastvalleyanimalclinic@frontiernet.net

Phone: 952-423-6800

Fax: 651-846-6188

Hours:

Mon – Fri: 8 AM – 6 PM
Sat: Hours vary. Please call before stopping in.

Sunday Closed

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