Animal Medical Center / New Client

Animal Medical Center

101 Progress Rd.
Gloversville, NY 12078

(518)883-6365

www.fultoncountyvet.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by filling this out online below or click here   to download and print it.


Thank you for your cooperation in letting us assist you.

New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Emergency Contact
First Name
Last Name
Emergency Contact Phone
Phone TypePhone Number
Emergency Contact E-Mail Address :
How did you learn about our practice?

How would you prefer your reminders to be sent?
Post Card
Email
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


Describe your pets diet:

Last fecal exam:

Medication your pet is allergic to:

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

Authorization:
(Check here to indicate you have read and agree to our terms and conditions: )
I hereby authorize the veterinarian to examine, prescribe for and/or treat the above described pet(s). I assume responsibility for all charges incurred in the care of our pet(s). I also understand that all professional fees are due at the time the services are rendered. If you have an urgent problem, please call first thing in the morning if you would like your pet to be seen that same day

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