New Client Form - American Animal Hospital

Name *

First

Last

Spouse/Co-Owner

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone

Spouse's Phone

How would you prefer we contact you? *

Phone Call
Text
Email

How would you like to receive your pet's reminders? *

Postcard
Email

Were you referred by anyone?

Pet Name *

Pet Breed *

Pet Date of Birth *

Pet Color *

Pet Sex *

Spayed or Neutered?

Spayed
Neutered
Neither

Is your pet microchipped? *

Yes
No

What is your pet's microchip number? *

What is the name of the microchip company? *

Has your pet had any previous illnesses or reactions?

Any allergies to medications, vaccines, or other?

Is your pet currently on any medications or eat a special diet?

Are there any concerns you would like to discuss with the veterinarian on you visit?

Does your pet have insurance? *

Yes
No

What is the name of the insurance company? *

What is the policy number? Please bring a blank claim form to the appointment. As a courtesy we will file the insurance claim for you at check out time!

All payments are due at time of service. Please feel free to ask for an estimate or medical treatment plan prior to providing services. We accept Visa, MasterCard, Discover, American Express, CareCredit, Cash, and check. *

I have read and understand.

We occasionally feature our patients on our website and social media pages. Please check here to authorize American Animal Hospital to share your pet's photo in this way. *

Yes
No

By signing below, I acknowledge I fully understand the terms of this agreement, If I do not pay the amount as agreed, past due accounts are subject to a 1.5% finance charge, minimum $1 and cost of collection, including attorney fees. I am the owner or authorized agent of the owner of the animal(s) presented. *

Digital Signature

New Client/New Pet Form