New Client Form - Chathams Small Animal Hospital

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Please Note: We will be closing early at 1 PM on Tuesday, December 31st and will be fully closed on Wednesday, January 1st in observance of New years!

New Client Form

Welcome to Chathams Small Animal Hospital! We look forward to meeting you and your pet! Please fill out the form below so we can get to know you better prior to your appointment. If you have any questions, feel free to call our office at 518-519-3606.

Registration

Name of Owner *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

I consent to receive SMS text messages from Chathams Small Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Alternate Phone

Email *

Spouse/Partner

Phone

Preferred Contact Method *

Phone
Email

How did you hear about us? *

Google
Facebook
Instagram
Sign / Walked by
Referral
Other

Who referred you, we'd love to thank them!

If Other, please explain

Patient Information

Pet's Name *

Species *

Cat
Dog
Other

If Other, please elaborate

Age

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed

Color *

List any known allergies

Other pets in the household? *

Would you like to add information for another pet? *

Pet's Name *

Species *

Cat
Dog
Other

If Other, please elaborate

Age

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed

Color *

List any known allergies

Would you like to add information for another pet? *

Pet's Name *

Species *

Cat
Dog
Other

If Other, please elaborate

Age

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed

Color *

List any known allergies

Please upload any of your pet's records that you may have

Click or drag files to this area to upload. You can upload up to 5 files.

Do you have pet insurance? *

If yes, please let us know which company

Policy #

Former Veterinarian Name/Hospital

Former Veterinarian's Phone Number

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospital treatment. *

I have read and agree

I hereby authorize the release of my pet’s medical records to another facility (boarding/daycare, insurance company, urgent care facility, etc.), should they be requested. *

Signature of Pet Owner *

Clear Signature

Date *

Our contact information is below!

Address

4042 Route 203

North Chatham, NY 12132

Click here for directions.

Our Hours

Mon: 8:00am-6:00pm
Tues: 7:00 am-7:00 pm
Wed: 7:00am-5:00pm
Thurs: 7:00am-7:00pm
Fri: 8:00am-6:00pm
Sat & Sun: Closed

Contact Us

Phone: 518-519-3606
Fax: 518-545-5554
Email: frontdesk@chathamssmallanimalhospital.com

Have a question? Please don’t hesitate to contact us using the form below. If you need immediate assistance, please call our team directly at 518-519-3606.

Name *

First

Last

Email *

Phone

I consent to receive SMS text messages from Chathams Small Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

How can we help you? *

Website