New Patient From

New Patient Form

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form. Thank you for your cooperation in letting us assist you.

Name*

Address*

City*

State*

Zip / Postal Code*

Phone*

Email Address*

Pet's Name *

Age: Years, Months *

Type of Pet

Breed *

Color *

Sex

Neutered / Spayed

Are Your Pet's Vaccines Current?

Do You have Medical records From Your Previous Veterinary Practice?

Please make sure to bring copies of all previous vaccination, health history, and lab results. You can also send documents to info@ampmidealpetcare.com

What was your previous Veterinary Hospital?

Do you provide permission to request Medical Records?

Reasons or conditions that prompted your visit? *

List Any Current Medications *

List Any Current Or Previous Medical Conditions *

List Any Allergies *

Please list any additional pets here

How would you like to receive reminders and communications from our office?

How did you hear about us? If a friend referred you, please give us their name

Or if you were referred by one of the following

PLEASE READ:

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal(s). I also understand that ALL PROFESSIONAL FEES ARE DUE AT TIME SERVICES ARE RENDERED.

APPOINTMENT POLICY:

New Clients are required to place a deposit of $95 for the first visit. You have 48 hours prior to the visit to cancel or reschedule this appointment without penalty. If the appointment is not kept or cancelled the $95 deposit is NON REFUNDABLE.

Type your last name in the box below to acknowledge that you have read and agree to the NON REFUNDABLE appointment cancellation policy. You cannot submit this form without typing in your last name.

Check this box to acknowledge that you have read and agree to the NON REFUNDABLE appointment cancellation policy. You cannot submit this form without checking this box

Thank you! Your submission has been received!

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New Patient Form

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