New Client FormHow did you hear about us?Neighbor / Friend (name):Another Vet (name):Internet search (i.e. Google, Yelp, Website, etc)The MTM ShopperDirect mailer/PostcardExterior SignNEW CLIENT / PATIENT INFORMATIONClient Name First Last Spouse / OtherAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneWork/Cellpreferred# Home CellEmail Other Email PET(s) INFORMATIONPet NameBreedColorBirthday PetCatDogMaleFemaleNeuteredSpayedLast VeterinarianWhat type of Heartworm prevention is pet onWhat type of Flea prevention is pet onMedical condition(s) we need to know aboutPet NameBreedColorBirthday PetCatDogMaleFemaleNeuteredSpayedLast VeterinarianWhat type of Heartworm prevention is pet onWhat type of Flea prevention is pet onMedical condition(s) we need to know aboutPet NameBreedColorBirthday PetCatDogMaleFemaleNeuteredSpayedLast VeterinarianWhat type of Heartworm prevention is pet onWhat type of Flea prevention is pet onMedical condition(s) we need to know aboutI hereby give permission to Hamilton Mill to take photos and videos of me and my pet(s) for the purpose of posting on social media sites and release and discharge Hamilton Mill from any and all claims arising out of use of the photos/videos. Hamilton Mill Animal Hospital has my permission to use the photos and videos. SignaturePRACTICE PHILOSOPHYThank you for choosing Hamilton Mill Animal Hospital. We are a full service hospital. Our philosophy is to practice quality Veterinary medicine. Our fees are based on our cost to provide this type of service. We do not bill. We accept cash, checks, VISA, Mastercard, Discover, American Express and Care Credit. I accept responsibility for payment for each visit.SignatureDate
