Ahwatukee Animal Care Hospital

10855 South 48th Street
Phoenix, AZ 85048

(480)893-0533

www.ahwatukeeanimalcare.com

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. you may also print this form and bring the completed form in with you to your first visit.

You must be 18 years of age or older to complete this form. 

Thank you for your cooperation in letting us assist you.

New Client

Date :
Name (required)
First Name (required)
Last Name (required)
Spouse's name
First Name
Last Name
Alternate Name on Account
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Home Phone (required)
Phone TypePhone Number (required)
Work Phone
Phone TypePhone Number
Cell Phone
Phone TypePhone Number
E-Mail Address (required) :
Driver's License

Place of Employment

How did you become aware of our hospital? (required)
Website
Hospital sign
Friend
Internet (other than our site)
Other


If referred, whom may we thank?
First Name
Last Name
Are we going to be your regular veterinarian?
(Are we going to be your regular veterinarian? (if yes, we will send you notices about your pet's reminders being due) Please check all that apply.)
Yes
No


If none of our veterinarians are your regular veterinarian, who is your vet.?

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :
Breed:

Sex:
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pets vaccines current? (required) :
If your pet is a canine -date of most recent Canine Distemper/Parvo vaccine :
Canine pet - Date of most recent Rabies vaccination :
Canine pet - Date of most recent Bordetella vaccine :
Canine pet - Date of most recent Rattlesnake vaccine :
If your pet is a feline - Date of most recent Distemper/Parvo vaccine :
Feline pet - Date of most recent Rabies vaccine :
Feline pet- Date of most recent Leukemia vaccine :
Has your pet had any reactions to vaccinations or medications? Please describe. (required)

Is your pet on any special diets or medications? Please specify.

Do you have your pet's medical records? :
Medical records at another veterinary practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records? (required)
Yes
No


Would you like us to call you for your appointment (required) :
Reasons or conditions that prompted your visit? (required)

Special requests or conditions? (required)

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 Ahwatukee Animal Care Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Deposits are required on all major medical/surgical cases, trauma cases, and hospitalizations. We do offer Care Credit as a method of making payments; please ask about this before services are provided. We do not carry open accounts. Any balance that remains over a period of 30 days will accrue a monthly finance charge of 4.5%. Any balance that I leave unpaid more than 30 days will be forwarded to Ahwatukee Animal Care Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. This hospital works in conjunction with the Arizona State District Attorneys office in reporting all bad check writers. I agree to pay any costs and attorney's fees necessary for the collection of any amount not paid when due. Ahwatukee Animal Care Hospital not accept personal checks. To decrease the spread of infectious diseases and parasites, hospitalized patients,day care participants, and/or boarded pets must be current on all vaccinations and be free of all internal and external parasites. If we determine that your pet is not current on vaccinations and/or has fleas and/or ticks, we reserve the right to provide vaccinations and parasite control when needed, and you will be charged accordingly. If you have information to provide proof of vaccinations, please leave it with the front desk staff so that the information may be entered into your pet's file. I have read and understood the payment policy and infectious disease/parasite control policies. I am the owner or authorized agent on this account. I have the right to make medical and financial decisions on this account.
I have read this statement and - (required)
I Agree
I Disagree


Name (required)
First Name (required)
Last Name (required)
**THE VERIFICATION CODE BELOW IS CASE SENSITIVE

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