New Client Form - Via Internet

If you would like to make an appointment please contact us by telephone. You can assist us to expedite your check in by submitting this form. Please allow 48 hours to be added to our data base. Welcome!

Thank you for your cooporation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Client's Birthdate (required)

Driver's License Number (required)

Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
Secondary Name(s) on the account:

E-Mail Address :
Pet's Name (required)

Age: Years, Months / Birthdate (required)

Type of Pet (required) :
Breed: (required)

Color: (required)

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary practice? (required)
Yes
No

Name and Phone Number of Former Veterinary Practice (required)

May we request a transfer of records? (required)
Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here: Name/Sex/Age/Species/Breed/Color

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 Amigo Animal Hospital 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 Amigo Animal Hospital'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 - (required)
I Agree
I Disagree


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