White Haven Vet Hospital

HC1 Box 10B
White Haven, PA 18661

(570)443-0966

whitehavenvet.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check-in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

Name & Email (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)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Species: (required) :
Breed:

Color:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pets vaccines current?
Does your pet have medical records?
Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at White Haven Veterinary Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to White Haven Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



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