Rohan and Harper

8470 Main Street
Williamsville, NY 14221

(716)634-1000

wheatfieldanimalhospital.com

New Client / Patient Form

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pets Name (required)

Type of Pet (required)
Dog
Cat
Other
Age (required)

Sex (required)
Male
Female
Is your pet neutered or spayed? (required)
Neutered
Spayed
Neither
Do you have your pets previous medical records? (required)
Yes
No
Name of Veterinarian or Hospital (required)

List of Medications

Payments
We accept cash, checks(with photo ID), MasterCard/VISA(with photo ID) and Care Credit. Payment is expected when services are rendered. We will gladly prepare you a written estimate of services prior to the treatment of your pet if you desire. I realize and understand that I am financially responsible for the care and treatment of my pet(s). I further agree that in the case of non-payment, a finance charge or interest fees and collections fees will apply.
I have read the above statement (required)
Yes
No

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