Pleasantville Animal Hospital, New York Veterinarian 914-769-3700 Pleasantville Animal Hospital, New York Veterinarian
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New Client Form
To ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us.
Your Name
Street Address
City, State, Zip
Home Phone

Work Phone

Mobile Phone
Would you like to receive text messages for appointment reminders?  
E-mail (preferred)
Spouse/Partner Name
Emergency Contact:  
Emergency Contact Name
(if other than spouse)
Emergency Contact's Relation to You
Emergency Contact's Phone
Is this person authorized to make decisions about your pet’s health?  
Were you referred to PAH by one of our clients?
# of Pets in Your Household
Pet Information: If you have more than one pet, you'll have the opportunity to add them after this form is submitted.
Pet Name
Species Dog     Cat     Other
If Other Species
Sex Male     Female
Date of Birth
Neutered/Spayed? Yes       No
Please describe your pet's daily diet
Pet Health History:  
Does your pet have any known allergies?
Can you provide us with your pet's vaccination history?
Please tell us what (if any) medications your pet is currently taking
Please tell us the reason for your visit
Have you scheduled an appointment already? Yes       No
When you are finished, click submit to send the form information
Pet Portal Care Credit
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