Home
Services
- Laparoscopy
Staff
Pet Info
News & Events
Contact Us

New Client Form

Pleasantville Animal Hospital > Contact Us > 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.

If you are human, leave this field blank.

Your Information

Your Name

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Mobile Phone

Would you like to receive text messages for appointment reminders?

Yes

Spouse/Partner Name

Were you referred to PAH by one of our clients?

# of Pets in Your Household

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?

Yes

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

Breed

Color

Sex

Male

Female

Date of Birth

Neutered/Spayed?

Yes

Microchipped?

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

If yes, for what day/time?

Missed Appointments Policy

I understand that there will be a charge for no show appointments that aren't canceled 24hr prior to the appointment. Check YES below: *

Yes

Captcha *

reCAPTCHA is required.

When you are finished, click submit to send the form information

Pleasantville Animal Hospital

10 Marble Ave
Thornwood, NY 10594

info@pleasantvillevet.com

Tel. 914-769-3700

Hours

Monday-Friday: 8am – 5:30pm
Saturday: 8am – 1:00pm