Client Registration Form





Client Information

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Email:
Home Phone:
Cell Phone:
Employer:
Work Phone:
Hobbies:
Interests:
Emergency contact:
Emergency phone:
Relation to owner:
Whom may we thank for referring you to AMC

 

Pet Information

Name:
Type of Pet:
If Other:
Age:
Sex:
Neutered/Spayed
At what age?
Birth Date:
Breed:
Color:
Other Pets at home?
How old was your pet when you obtained them?
Where did you obtain your pet?
Has your pet been to another veterinarian?
If yes, which veterinarian?

 

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility of all charges incurred in the case of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. NO PARTIAL PAYMENTS.

Check to confirm submission.

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  • Some of our patients celebrating the holiday. It is the year of the dog!

    amcmqt: "Some of our patients celebrating the holiday. It is the year of the dog!"
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  • Happy Lunar New Year! One of our staff members featured here was born in the year of the dog.

    amcmqt: "Happy Lunar New Year! One of our staff members featured here was born in the year of the dog."
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    0
  • Today was Treats Thursday! We provided treats to both our clients and their pets. Here were some of the yummy choices. We love being able to serve you today.

    amcmqt: "Today was Treats Thursday! We provided treats to both our clients and their pets. Here were some of the yummy choices. We love being able to serve you today."
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    0
  • We love our clients and have special events running all week to show how much we appreciate you choosing us for your pet care.

    amcmqt: "We love our clients and have special events running all week to show how much we appreciate you choosing us for your pet care."
    23
    1
  • Happy Valentine’s Day from Amc 💕 clients enjoyed complimentary #ToeNailTrimTuesday in celebration. 💅🏽 New perks everyday this week because we love you. 💘#ToeNailTransformation #AnimalMedicalCenter #AMC #Mqt

    amcmqt: "Happy Valentine’s Day from Amc 💕 clients enjoyed complimentary #ToeNailTrimTuesday in celebration. 💅🏽 New perks everyday this week because we love you. 💘#ToeNailTransformation #AnimalMedicalCenter #AMC #Mqt"
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  • Today was Fat Tuesday. We had chicken gumbo for staff and free nail trims for patients.

    amcmqt: "Today was Fat Tuesday. We had chicken gumbo for staff and free nail trims for patients."
    9
    0
  • Dr.Gerrish with her dog Mabel just after she finished in the show ring at The Westminster Dog show today.

    amcmqt: "Dr.Gerrish with her dog Mabel just after she finished in the show ring at The Westminster Dog show today."
    17
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  • Oliver is in to be neutered today. He weighs in at 98 pounds. Here are a couple of photos from a year ago when he was coming in for his puppy visits.

    amcmqt: "Oliver is in to be neutered today. He weighs in at 98 pounds. Here are a couple of photos from a year ago when he was coming in for his puppy visits."
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  • This morning Dr.Holmstrom was wearing a sweater with a Chow in honor of the Chinese New Year of the dog. Emily brought her cat Luna in for a recheck and was wearing her cat sweater. We had to take a photo.

    amcmqt: "This morning Dr.Holmstrom was wearing a sweater with a Chow in honor of the Chinese New Year of the dog. Emily brought her cat Luna in for a recheck and was wearing her cat sweater. We had to take a photo."
    18
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  • Harper visited the clinic to start her puppy vaccinations and sample some of our fear free snacks.#fearfree #frenchbulldog

    amcmqt: "Harper visited the clinic to start her puppy vaccinations and sample some of our fear free snacks.#fearfree #frenchbulldog"
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