Animal Medical Center New Client form

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as possible. If you have questions please leave the section blank and we will be happy to help you. We look forward to serving you and your pet.

When you are done filling out this form hit the submit button to send it to us via e-mail or print it and bring it to your appointment.
CLIENT INFORMATION:
First Name: Last Name:

Address: City: Zip:
Home Phone: Cell Phone:
Work Phone: E-mail:
Employer: How did you hear about our practice:
*Who may we thank for your visit today:

PET INFORMATION:

Pet's Name: Type of Pet:
If other please type in here: Breed:
Gender: Date of Birth: Color:
Where did you obtain your pet:
Length of time owned:
Date Vaccines where given: Rabies: DA2PP: FVRCPP (Feline): CIV: Lepto:
Previous Veterinarian / Hospital:
Prior Illness 550 characters maximum. The doctor will take a full history::
Prior Surgery: 550 characters maximum. The doctor will take a full history:
Medications:
Reason for visit today: 550 characters maximum. The doctor will take a full history:
PAYMENT:
Payment will be made as:
Cash: Visa: Mastercard: American Express: Discover: Care Credit: Check: Combined:
We will gladly prepare a written estimate of service fees if you desire. All professional fees are due at the time services are rendered. In cases of extreme medical or surgical procedures where full payment may be due difficult at dischrge, we accept major credit cards, Care Credit, or can establish a payment arrangement if approved in advance of treatment. If you carry a balance for more than 30 days we reserve the right to charge the balance to any credit card the client has used at Animal Medical Center. There will be a $25.00 service charge for any returned check. Sorry we do not accept business or company checks.

Signature:
If you are e-mailing this form please type your name in this section, it will act as your confirmation that all information supplied is correct. If you print it out, please sign this area.
Date: