Owner InformationOwner's Name First Last Spouse/CO-Owner's Name First Last Home PhoneWork PhoneCell Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's EmployerSpouse EmployerIF NECESSARY, MAY WE CALL YOU AT WORK? Yes NoPet InformationName(Required) First Date of Birth(Required)Sex(Required)Male NeuteredMale IntactFemale SpayedFemale IntactBreed(Required)Color/Markings(Required)Last VeterinarianHow did you learn about Animal Medical Clinc? Sign Yellow Pages Internet Referral OtherIf other, please explain.If personal recommendation, who may we thank?Fees for all services, medications, and products are due as they are performed. We require a deposit when your pet is admitted for major medical, trauma, or surgical care and when hospitalized. Please check the method of payment you will be using today: Cash Check Debit Visa MasterCard Discover*We use electronic verification for checks. All checks are processed electronically immediately as we receive them. For your convenience, and to save you a paper check, you might prefer to use your check/debit card. A driver’s license, phone number and date of birth are required on ALL paper checks. A minimum returned check fee of $30 will apply for all returned checks other processing fees may occur.To help us respond to your individual needs, please check one in each of the three sections below which most applies to you: I feel that my pet is another member of our family I feel that my pet is just a pet I want the best medical care available for my pet; please recommend anything that you believe is beneficial for my pets optimal health. I want good medical care for my pet, but there is a limit to what I am able to do I want you to do only the services that I request. I feel my pet should be thoroughly examined by a veterinarian at least once a year. I feel my pet only needs to be examined by a veterinarian when there is a problemDo you give us permission to use photos of your pets on our website and social media platforms? Yes NoWould you like to be contacted about scheduling an appointment?(Required) Yes NoPhone to contact(Required)Consent(Required) I assume responsibility for all the charges incurred in the care of this animal. I also understand that these charges MUST BE PAID IN FULL AT THE TIME OF RELEASE and that a deposit may be required for treatment.CAPTCHAΔ
