Boston Valley Animal Hospital

7333 Boston State Rd
Hamburg, NY 14075

(716)312-0300

bostonvalleyanimalhospital.com

NEW CLIENT REGISTRATION FORM

If you would like to make an appointment, you can assist us in expediting your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Cell phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years

Type of Pet (required) :
Color (required)

Breed (required)

Sex: (required)
Male
Female


Are your pets vaccinations current?
yes
no


Neutered/Spayed
Neutered
Spayed
Not spayed/neutered


Do you have the pets medical records?
yes
no


Name of Former Veterinary Practice

Former Veterinary Practice phone number

May we request a transfer of records? (required)
Yes
No


Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Boston Valley Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Boston Valley Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and - (required)
I Agree
I Disagree



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