New Client Check In

If you would like us to contact you to set-up an appointment, you may fill out and submit this form. Our staff will contact you within 1-2 business days.  If your pet has a more urgent medical condition, please contact our office directly at (515)967-4281.

Thank you and we look forward to serving you and your pet.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Home Phone (required)
Phone TypePhone Number (required)
Alternate Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed (required)
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 Altoona Veterinary 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 Altoona Veterinary 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


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