Hamlin Animal Hospital

Client Information

Your Name

First Last

Spouse or Partner's Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Spouse or Partner's Phone

Email(Required)

Pet Information

Name

Age/DOB

Colors

Breed

Species

Canine

Feline

Other

Sex

Male

Male – neutered

Female

Female – spayed

Up to date on vaccines?

Yes

No

Previous Veterinary Clinic

Please tell us about your pet’s previous veterinary care, if applicable.

Would you like to make an appointment?(Required)

Yes

No

Appointment Details

What is the appointment for?(Required)

If this is an emergency, or your pet is in pain or injured, or you need an appointment today please call our office.

1st Choice Appointment Date(Required)

MM slash DD slash YYYY

Time(Required)

Morning

Midday

Evening

2nd Choice Appointment Date(Required)

MM slash DD slash YYYY

Time(Required)

Morning

Midday

Evening

Appointment Reason(Required)

Consent(Required)

I certify that I am the legal owner/agent of the above-mentioned pet and I hereby authorize Hamlin Animal Hospital to examine, prescribe for, and/or treat the above-described pet(s). I assume financial responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.

Signature

CAPTCHA

Date

MM slash DD slash YYYY