New Client Registration Name(Required) Last Name First Name Spouse Mailing AddressNumber / Street(Required)City(Required)State(Required)Zip(Required)Phone NumberCell(Required)AlternateOtherEmail(Required) Physical AddressSame as mailing address Same as mailing address Number / Street(Required)City(Required)State(Required)Zip(Required)AuthorizationsPhoto/Video(Required) Yes No Text(Required) Yes No Email(Required) Yes No Requesting Records(Required) Yes No Do you intend to use us as your new primary care veterinarian?(Required)Previous VeterinarianClinic Name(Required)PhoneCity / StateReferred By(Required) Web Search Mailed Advertisement Drive By Current Client Local Business Other Local Business NameClient NamePlease specify if other:Pets Name:(Required)Approximate D.O.B./Age(Required)ColorBreed(Required)Sex(Required) Male Female Altered(Required) Yes No Microchip #(Required)Allergies(Required)Health ConditionsMedications/SupplementsI herby authorize the staff of AMS to render treament to my pets while in their care. I understand in the even of any unusual or mergency circumstance, the staff will make every attempt to contact me or my designated representative before proceding with treatment. I verify that I am the legal owner of this(these) animals and I understand that I am financially responsible for all services and medications provided. I have been provided a copy of general hospital policies and agree to follow them to the best of my ability.Name(Required)Date(Required)Digital Signature(Required)PhoneThis field is for validation purposes and should be left unchanged.
