Welcome Form

Welcome
We are happy to welcome your new pet! Are you... *

new client with a new pet current client with a new pet
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number (Landline)
Please enter a valid phone number.
Cell Phone Number *
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email *
example@example.com
Name of spouse, partner, or other person you would like on the account. Please include name, cell phone, or other contact information for this person.
How did you hear about us? *
If you were referred by a family or friend, please specify name for a referral gift certificate.
Date of appointment at the Village Veterinary Clinic of Hamburg *

Month Day Year
Date
Pet *

Name Breed
Type of pet? *

Dog Cat
Date of Birth *

Month Day Year
Date
Male or Female? *

Male Female
Spayed or Neutered? *

Yes, neutered No, not neutered Yes, spayed No, not spayed
Are there any known allergies in your household- both human or pet? Food? Medication? We give treats in our exams, such as cheese and peanut butter. Please let us know of any allergies prior to exposure. *
All payments are due at the time of services. A deposit is due if a patient is hospitalized. The remaining balance will be due upon discharge. We accept Visa, Mastercard, Discover, Care Credit, or Cash. NO CHECKS.

Please download our FREE pet app, PetDesk!
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