Hammond AH- Life Unleashed Welcome Form

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Thank you for choosing us for your pet’s healthcare, boarding, and/or grooming. So that we may best serve you and your pet, please complete the following:
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Client Information
Name
Spouse
E-mail
Home Phone
Employer
Work Phone
Spouse Employer
Spouse Work Phone
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DL#
Cell Phone
Spouse DL#
Spouse Cell Phone
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
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American Samoa
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Anguilla
Antigua and Barbuda
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Australia
Austria
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The Bahamas
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Belize
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Mali
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Mayotte
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
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Saint Martin
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Samoa
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Senegal
Serbia
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Singapore
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Slovenia
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Somalia
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eSwatini
Sweden
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Syria
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Tajikistan
Tanzania
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Turkey
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Western Sahara
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Other
Country
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Pet Information
Pet’s Name
Dog
Cat
Species
Breed
Male
Female
Sex
Color
Yes
No
Spayed or Neutered?
Date of Birth
Kept indoors, outdoors, or both?
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At what age was pet obtained?
Rescue
Friend
Breeder
Other
From where was pet obtained?
If other, Please Specify
How did you hear about us?
Previous/Current Veterinarian (for this pet)
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Medications (name, dosage, frequency)
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Brief Medical History
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Terms and Conditions* This field is required.I hereby authorize Hammond Animal Hospital, Boarding & Grooming, and its doctors and staff, to provide services to the above described pet. To prevent the spread of infectious diseases and parasites, hospitalized or boarded animals must be current on vaccinations and wellness screenings (as per our Preventive Healthcare guidelines). I hereby authorize the doctors and staff of Hammond Animal Hospital to examine, prescribe for, and treat the above described pet. I assume all responsibility for all charges incurred in the care of said pet. I understand that payment is due at the time of services. I also understand that I am responsible for any costs and/or charges necessary for the collection of any amount not paid at the time of service, and that a minimum $25.00 charge will be assessed for a returned check.
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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