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Ph: (516) 223-1555

1864 Grand Avenue, Baldwin NY 11510

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Back to Website
Client Center
New Client Form
Request Appointment
Home Delivery
SHOP
Contact

New Client Form

Thank you for giving Baldwin Animal Hospital the opportunity to care for your pet. So that we may become better acquainted, please provide the following:

Required fields are marked {*}

Client Information
Owner(s) Name:*
First Last
Owner(s) Address:*
Street Address Address Line 2 City State ZIP Code
Owner(s) Email:*
Phone:*
- Home
- Cell
- Work
Home Phone:
Cell Phone:
Work Phone:
Would you like to add a Spouse/Co-Owner?*
- Yes
- No
Spouse/Co-Owner Name:
First Last
Spouse/Co-Owner Phone:
How did you become aware of our hospital?*
- Yellow Book (Local)
- Yellow Pages
- Internet
- Hospital Sign
- Website
- Recommended from a friend
If recommended by a friend, whom can we thank?
Pet Information
Pet's Name:*
Birth Date:*
MM slash DD slash YYYY
Species*
Breed:
Sex:*
- Male
- Female
Spayed/Neutered:*
- Yes
- No
Color:*
Date of last vaccination(s):
MM slash DD slash YYYY
Last Vet Visit:
MM slash DD slash YYYY
Surgeries/Chronic Health Problems:
Please list any other pet family members:
I understand that all fees are due when services are rendered.*
I Understand
Forms of payment accepted, check any/all that may apply:
- Cash
- Debit
- Visa
- Mastercard
- Discover
- American Express
- CareCredit
(In the event arrangements are made to accept a Check and it’s returned for non-payment there is a $ 25.00 fee)
*By providing us with your e-mail address you may open a personal pet portal through our website, allowing you to view your pets’ vaccine history, refill medications and contact us.
May we have permission to publish your pet(s) photo to the internet/our website:*
- Yes
- No
Owner Signature (your name here serves as your digital signature)*
First Last
Date Submitted*
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Baldwin Animal Hospital © 2013 – 2021
1864 Gran Avenue,Baldwin, NY 11510
Veterinarians near Hempstead, Long Beach, Merrick, Oceanside, Point Lookout, Rockville Center, Freeport and Baldwin NY.
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