New Clients Client InformationYour Name First Last Spouse or Partner's Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP PhoneSpouse or Partner's PhoneEmail Pet InformationNameAge/DOBColorsSpecies Canine Feline BreedSex Male Male - neutered Female Female - spayedUp to date on vaccines? Yes NoPrevious Veterinary ClinicPlease tell us about your pet's previous veterinary care, if applicable.I certify that I am the legal owner/agent of the above-mentioned pet and I hereby authorize Hamlin Animal Hospital 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.SignatureΔ
