Information Sheet
PARK HILLS ANIMAL HOSPITAL | DEER PARK, NY
Date
-
Month
-
Day
Year
Date
Owner's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Alternate Phone
-
Area Code
Phone Number
Email
example@example.com
Place of Employment
Driver's License Number (If you are going to be paying by check today or in the future.)
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Phone Number
First Name
Last Name
Please provide the name of your Emergency Contact as well as their relationship to you:
How did you hear about us?
Phonebook
Another Client
Other Vet
TV
Advertisement
Other
Pet's Name
Species
Cat
Dog
Bird
Reptile
Ferret
Rabbit
Hamster
Guinea Pig
Other
Breed
Age
Date of Birth
Color
Sex
Male
Female
Unknown
Spayed / Neutered
Yes
No
Unsure
Please indicate the date of your pet's last visit to the Veterinarian including the name of the Doctor and Animal Hospital the pet was seen at.
Other Pets
Are they patients of Sachem Animal Hospital or Park Hills Animal Hospital?
Fee
I understand that I can receive a written fee estimate if I request one. I understand that a final fee will be based on actual services rendered, and agree to pay the full amount due at the time services are rendered or of the animal’s release from the Hospital, including any boarding fees Should the Hospital have to institute collection proceedings to recover any amount owed by me, I agree to pay all costs of such collection proceedings, including any legal fees incurred.
Signature of Owner or Authorized Agent
Submit
Should be Empty: