New Patient/Prospective Client

Date:  
Time:  
First name  
Middle name :  
Last Name :
Address  
City  
State  
Zip  
Cell/Work Number  
Email  
Employer’s Name & Address  

How did you first hear about our Hospital?

Individual
 Yellow Pages      Web Site
Hospital someone we may thank
Sign Other
We consider our pet(s)  part of the family    just as pets    
In case of Emergency please call  
Tele #  

We will gladly provide a written estimate. Please ask the receptionist/Doctor. Professional fees are due at the time of services rendered. Method of payment Cash, Check, VISA/MC, AMEX.

"***Checks to be accepted only when cash or credit is not available and we will request a valid driver's license/State ID, social security number, and check to run through a check guarantee service before accepting checks as a form of payment.

Please complete the following:

Credit Card No  
Bank  
Signature  
Exp. Date  
Driver’s License  
State  
SSN  

We also accept Care Credit, please call or come in to find out how you can be approved for Care Credit today

At Ambassador Animal Hospital, we work hard to prevent the spreading of infectious diseases and internal/external parasites. All pets here for hospitalization, boarding or grooming will be required to be current on all vaccines and free of internal parasites unless otherwise instructed by Dr. Roy. I authorize Ambassador Animal Hospital to provide any vaccines and parasite control to my pet if not current or suffering from any parasites

Accept  Decline
   
Pet Name   Breed  Color
Birth Date
 Sex
Duration Owned
Diet
Heart Worm Test  
Heart Worm Prev  
Dog Vaccinations: DHLPP/Distemper
  Rabies : Bordetella : Corona : Lyme :
Fecal Parasite : Dentistry : Prior Surgery:    
Vaccination Cats : Felv/FIV Test Positive FVRCP : FVRCP/Distemper : Rabies : Chlamydia :
FIP : FIV : Prior Surgery :      
Has your pet been treated for any illness in the past? Specify illness, medication, dosage etc.
What service is needed at this time?