White Haven Veterinary Hospital

88 State Route 940
White Haven, PA 18661

(570)443-0966

www.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 the form below.

 Thank you for your cooperation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
E-Mail Address :
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Primary Phone (required)
Phone TypePhone Number (required)
Secondary Phone (required)
Phone TypePhone Number (required)
Pet's Name (Additional Pets may be entered at the bottom of form) (required)

Age: Date of Birth OR Best Guess

Species: (required) :
Breed:

Color:

Sex: (required)

Male
Female


Neutered/Spayed

Neutered
Spayed


Do you have your medical records and/or vaccine history that you can bring with you to your appointment OR email to us prior?
May we request a transfer of records from your previous veterinarian? Please provide their information below.

Reasons or conditions that prompted your visit?

Any major medical history we should know about on your pet?

Please list any additional pets here


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