Animal Medical Hospital

779 Peninsula Blvd.
Hempstead, New York 11550

(516)483-7007

www.animalmedicalhosp.com

Welcome New Clients!


New Client Form


If your pet has visited another veterinarian or received vaccinations elsewhere, we kindly ask that you arrange to have these records sent to us via email or fax at least 24 hours prior to your appointment. If you have your pet's records, you may take a clear photo of them and email them to us. Please also bring any records to have to your pet's first exam. Thank you! 


Animal Medical Hospital

Email: AMH7007@aol.com
Fax: 516-776-9204


Please do not use this form if your pet is experiencing an emergency. If there is an emergency, call us right away at 516-483-7007. 

New Client Form

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Primary Phone # (required)
Phone TypePhone Number (required)
Secondary Phone #
Phone TypePhone Number
E-Mail Address (required) :
Preferred Contact Method (required) :
Spouse/Partner Name
First Name
Last Name
Spouse/Partner Phone #
Phone TypePhone Number
How did you hear about us? (required) :
How did you hear about us (if you answered "other")

Authorization:
By submitting this form, I hereby authorize the doctors and staff to diagnose, prescribe for, and treat the pet described below. I assume all responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time services are rendered. In the case of hospitalization, I will be required to leave a substantial deposit. The remaining balance must be paid in full at the time of discharge of the pet. I authorize photos and video to be taken of my pet's care for training, website, and educational purposes. Please present a valid drivers license or photo ID at the time of check-in.
Financial Information: How do you plan to pay for today's visit? :
Do you have pet insurance? If not, we'd be happy to tell you more about how pet insurance can help! :
Pet's Name (required)

Approximate Age: Years, Months (required)

Type of Pet (required) :
Breed: (required)

Color: (required)

Sex: (required)

Male
Female


Is your pet spayed (females) or neutered (males)? (required) :
Does your pet live indoors, outdoors or both? (required) :
Where did you get your pet? (required)

When did you get your pet? (required)

Pets approximate age when acquired?

Is your pet Microchipped? (required) :
Has your pet ever visited a veterinarian before? If so, approximate date of last examination? (required)

Last vaccination dates:

Please list past veterinarians your pet has visited: (required)

Please list any other pets you currently own: (required)

Kindly list any previous medical or surgical problems and current medications: (required)

Is your pet currently receiving any Heartworm Preventative? (required) :
Brand Name (of Heartworm preventative)

What Flea & Tick preventative are you currently using on your pet(s)? (required)

What brand of food is your pet currently eating? How much do you feed him or her daily? (required)

Does your pet get any table scraps? If so, approximately how often? (required)

Describe your pet's temperament (personality) : (required)

Reasons or conditions that prompted your visit? (required)

Authorized Representatives:
The individuals listed below are authorized representatives to act on your behalf in cases dealing with the pet listed above. They are authorized to obtain medical information regarding your pet, to admit and pick up your pet from our facility, and give verbal and/or written authorization to perform medical services and procedures. The individuals listed below are required to show photo identification when acting as your authorized representative.
Authorized Representative #1 (Full name, relationship to you, and phone number)

Authorized Representative #2 (Full name, relationship to you, and phone number)

Authorized Representative #3 (Full name, relationship to you, and phone number)


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