New Client

FM 1960 ANIMAL HOSPITAL

Dr. K. N. McLaughlin Dr. D. L. Simpson

PET PORTAL IS HERE!!

Click on the PET PORTAL icon to access your pet's information, make appointments and request medication refills -All 24 hours a day, 7 days a week!

New Client Check In

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 cooporation in letting us assist you.

Form - New Client

Name, Email & Drivers License (required)
First Name (required)	Last Name (required)

E-Mail Address :

Drivers License No & State (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Home Phone (required)
Phone Type	Phone Number (required)

Work Phone (required)
Phone Type	Phone Number (required)

Cell Phone
Phone Type	Phone Number

Spouses Work Phone
Phone Type	Phone Number

Spouses Cell Phone
Phone Type	Phone Number

Text Area

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at FM 1960 Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to FM 1960 Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and -
I Agree
I Disagree

The verification code below ensures the form is not submitted by a computer

Verification Code :

Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.