Saint James Animal Hospital

538 North Country Road
Saint James, NY 11780

(631)584-6336

www.stjamesanimalhospital.com

Welcome

Name
First Name
Last Name
Spouse

E-Mail Address :
Address
Street Address
City
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State / Province
Zip / Postal Code
Primary Phone
Phone TypePhone Number
Secondary Phone
Phone TypePhone Number
How did you hear about us?

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Enter your pet information here:
Name

DOB

Species

Breed

Weight (in lbs)

Color

Sex

Male
Female


Allergy

Rabies

Microchip

Name of previous Veterinary Hospital

Phone Number to request prior records
Phone TypePhone Number
AUTHORIZATION & HCP Acknowledgement
Please read carefully:
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.
Regarding the text above:

I Agree
I Disagree


Please read regarding HCP
I hereby acknowledge that the Health Care Plan (HCP) was explained to me and understand that failure to adhere to the HCP policy and protocol will result in voiding of the HCP.
Regarding the text above:

I Agree
I Disagree



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