New Client FormHow did you hear about us?*NEW CLIENT / PATIENT INFORMATION Client Name* First Last Spouse / Other*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell*Spouse Phonepreferred#* Home Cell Email* Appointment Date* PET(s) INFORMATION Pet Name*Breed*Color*Birthday* Species**MaleFemale*NeuteredSpayedUnalteredLast VeterinarianMedical condition(s) we need to know about*Pet NameBreedColorBirthday SpeciesMaleFemaleNeuteredSpayedUnalteredLast VeterinarianMedical condition(s) we need to know aboutPet NameBreedColorBirthday SpeciesMaleFemaleNeuteredSpayedUnalteredLast VeterinarianMedical 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. Signature*(social media)PRACTICE 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. Signature*(practice philosophy)Date*
