New Client

New Client Information

First, allow us to welcome you to our practice! On behalf of our Doctors and staff, thank you for choosing us for your pet(s) veterinary care. We pride ourselves on not only providing superior medical care, advice, and pet care products, but also by doing so in a warm, friendly, and compassionate manner. If you need assistance in setting up an appointment, please call us at 215-949-1010 and we would be happy to assist you.

We thank you for taking the time to fill out the following form which will expedite your check-in time at the hospital. If you have more than one pet, please fill out an additional "New Pet Form" also located under the "Forms" tab. We look forward to meeting you and your pet(s) soon!

Sincerely,
The Staff at The Animals' Hospital of Levittown

Form - New Client

Name & Email (required)
First Name (required)	Last Name (required)

E-Mail Address (required) :

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Phone Number (required)
Phone Type	Phone Number (required)

Payment Information

Accepted methods of payment
The Animals' Hospital accepts Cash, Personal Checks, and Visa, Mastercard, Discover, and Debit Cards. We apologize for any inconvenience but we do not accept American Express.

If you plan on paying by check, please provide your driver's license number:

Appointment Information

Have you already scheduled your appointment? (required) :

If yes, what is the date and time of your appointment? (If you haven't scheduled, please write N/A) (required)

If no, would you like us to call you to schedule an appointment? (required) :

Do you have any special requests or conditions we should know about?

How did you find us?

How did you hear about our practice? (required) :

If you heard about us through a friend, please provide their name; we reward referrals.

Pet Information

Pet's Name (required)

Species (required) :

If you selected other, please read the following:
We apologize for any inconvenience, but at this time we are unable to serve exotic animals. Please call our office for some phone numbers of other practices in the area that do.

Breed: (required)

Color/Unique Markings: (required)

Gender (required) :

Age/Birthday: (Years/Months) (required)

Are there any medical or temperamental problems with your pet that we should know about? (required) :

If you answered yes to the above question, please explain: (i.e. needs female doctor, needs muzzle)

Optional Information

What do you usually feed your pet?

Does your pet spend much time outdoors? If yes, please explain:

Is there anything else you feel we should know about you or your pet?

Disclaimer

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 The Animals' Hospital of Levittown 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 The Animals' Hospital of Levittown'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

The verification code below ensures the form is not submitted by a computer

Verification Code :

Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.