New Client Registration
Please fill out your contact and pet information to register as a new client at our animal hospital.
Owner Contact Information
Please provide your contact details below.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Honduras
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
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Secondary Contact Name
First Name
Last Name
Secondary Contact Phone Number
Please enter a valid phone number.
Pet Information
Please enter information for each pet. Click 'Add Row' to add another pet.
Pet Details
*
Permission for Pictures on Social Media
I grant Hamilton Crossing permission to use photos and videos of your pet for promotional purposes, including but not limited to social media, our website, and other marketing materials. These images and videos may be shared to help promote our services and celebrate the pets we care for.
Do you give permission to use pictures and videos of your pet?
*
Please Select
Yes
No
Please read below and sign:
Payment is due at time of service. We accept cash, check, debit cards, Care Credit, and most major credit cards. If for any unforeseen reason your check is dishonored by your bank, Hamilton Crossing Animal Hospital reserves the right to charge a fee of $45. We will gladly prepare a written estimate if you so desire. Please ask PRIOR to approving any treatments or services. Due to state law & insurance requirements, ALL pets MUST be current on RABIES vaccinations. I hereby authorize Hamilton Crossing Animal Hospital to receive, prescribe, treat or perform surgery upon the above listed pets, as well as any future pets that I add to my account. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from this hospital or the service is otherwise terminated. I agree to pay all costs associated with my pet in the event collection efforts become necessary. If I neglect to pick up my pet within 5 days of discharge date and do not notify the hospital within that time period, they will assume the pet is abandoned and I authorize Hamilton Crossing Animal Hospital to rehome my pet as they deem best and or necessary. By completing this form, you authorize us to send you text notifications through our online service, Vello, regarding lab results, medication availability for pick-up, and appointment confirmations. These messages are designed to keep you informed and ensure timely care for your pet.
Signature (Please sign below to confirm your information and agreement to our policies)
*
Register
Register
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