The Animal Medical 
Hospital and Bird Clinic
779 Peninsula Boulevard
Hempstead, NY 11550-7222
Ph: 516-483-7007
Fax: 516-776-9204
 

Whitestone Veterinary Care
22-22 154th Street
Whitestone, NY 11357
Ph: 718-888-0400
Fax: 718-701-5942
 

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Animal Medical Hospital and
Whitestone Veterinary Care

Welcome to Our Site

Form - Whitestone Vet Care New Clients

Name
First Name
Last Name
Address
Street Address
City
State/Province
Zip/Postal Code
,
Home Phone
Phone TypePhone Number
Cell Phone
Phone TypePhone Number
Please send me recent veterinary news and practice specials via e-mail?
E-Mail Address :
How were you referred to our practice?
Google
Queens Yellow Pages
Queens Yellow Book
Yahoo
In the neighborhood
By a friend

If referred by a friend, please tell us who so we may thank them for their referral.

What form of Payment will you use at your appointment?
Cash
Credit Card (We accept all major credit Cards)
I am not sure it will depend on the total, cash or credit

Pet Information
Pet's Name

Species
Dog
Cat

Sex
Male
Neutered Male
Female
Spayed Female

Date of Birth / Age

Reason for Visit

Please tell us your ideal appointment days. Mornings, afternoons or evenings?

Brand of Pet Food. How much do you feed daily?

Do you feed your animal table scraps? If yes, how often?

Check box if your animal is currently using a monthly flea prevention?
Which brand?

Check box if your animal is currently using a monthly heartworm prevention?
Which brand?

Previous Medical History
Appoximate date of last veterinary visit

Vaccination Status
Vaccinations are up to date
No, I need to update my pets vaccinations
I am not sure

Please contact my previous veterinarian for previous medical history.
Previous Veterinary Practice Name

Phone Number


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