New Client Form: Williamsburg Animal Clinic

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In order to make your pet’s first visit with us even easier, please fill out the New Client Form below and click ‘Submit’. We ask that you please arrive 15 minutes prior to your pet’s initial exam.

If you have any questions, please call us at (718) 302-2420.
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Your Name* This field is required.
First Name
Last Name
3
Spouse or Partner's Name
First Name
Last Name
4
Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
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
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Contact Information
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How did you hear about us?* This field is required.Choose as many as apply.
Drive by/Signage
Facebook
Google Search
Yelp
Nextdoor
Referred by a friend
DOGMA
Other
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If you chose 'referred by a friend,' please provide your friend's full name.They'll receive a $50 referral credit as our way of saying thank you. Help us spread the love!
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Pet Information* This field is required.Please tell us about your pet. If you'd like to make an appointment for more than one pet, form fields for an additional pet will be made available on the next slide.
Canine
Please Select
Canine
Feline
Other
Species
Animal's Name
Breed
DOB (Actual or Approximate)
Male
Male
Male
Female
Sex Unknown
Sex
Color/Markings
Yes
Please Select
Yes
No
Unknown
Spayed/Neutered
Yes
Please Select
Yes
No
Unsure
Up to Date on Vaccines?
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Would you like to add another pet as a new patient with us?
YESNO
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Additional Pet Information* This field is required.If you have more than one pet, please provide information on your additional pet here.
Canine
Please Select
Canine
Feline
Other
Species
Animal's Name
Breed
DOB (Actual or Approximate)
Male
Male
Male
Female
Sex Unknown
Sex
Color/Markings
Yes
Please Select
Yes
No
Unknown
Spayed/Neutered
Yes
Please Select
Yes
No
Unsure
Up to Date on Vaccines?
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Previous Veterinary ClinicPlease tell us about your pet's previous veterinary care, if applicable.
Please Select
Please Select
Yes
No
Does your pet have a previous veterinary clinic?
What is the name of your pet's previous veterinary clinic?
Please Select
Please Select
Yes
No
Does your pet have a health insurance plan?
What health insurance plan does your pet have?
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Do we have your permission to post photos of your pet(s) on our social media pages, including Facebook and Instagram?
YESNO
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I certify that I am the legal owner/agent of the above-mentioned pet and I hereby authorize Williamsburg Animal Clinic 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
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