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
 

powered by RatePoint Follow WhitestoneVet on Twitter

Animal Medical Hospital and
Whitestone Veterinary Care

Welcome to Our Site

Form - AMH New Client

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 contact me via e-mail with recent veterinary news and your practice specials.
E-Mail Address :
How were you referred to our practice?
Google
Yellow Book
Yellow Pages
Yahoo
In the Neighborhood
Referred 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
Check (must have identification and check must be verified through our Certegy system)
Credit Card (we accept all major credit cards)
Cash or credit depending on the total of the visit

Pet Information
Pet's Name

Species
Dog
Cat

Sex
Male
Neutered Male
Female
Spayed Female

Birthday / Age

Reason for Visit

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

Brand of pet food do you use. How much do you feel daily?

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

Please check box if your animal is currently using monthly flea prevention.
Brand of flea prevention

Please check box if your animal is currently using a monthly heartworm prevention.
Brand of heartworm prevention

Previous History
Approximate date of last veterinary visit

Vaccination Status
Vaccinations are up to date
No, vaccinations need to be updated
I am not sure

Please contact my previous veterinarian for previous medical history.
Previous veterinary practice name

Phone Number


The verification code below ensures the form is not submitted by a computer
Verification Code :
Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.