New to At Home Animal Clinic? We’re so excited to meet you and your pet! Fill out the form below to get started! Owner's Name(Required) Owner's First Name Owner's Last Name Co-Owner's Name Co-Owner's First Name Co-Owner's Last Name Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner Cell Phone(Required)Co-Owner Cell PhoneEmail Where have your pets had prior veterinary care? Please contact your previous clinic to have your pet’s medical records emailed to us at email@example.com or faxed to (651) 351-2423.Pet #1 Pet Name(Required) Species(Required) Breed(Required) Sex(Required) Spayed or Neutered(Required) Yes No Color(Required) Birthdate(Required) MM slash DD slash YYYY Pet #2 Pet Name Species Breed Sex Spayed or Neutered Yes No Color Birthdate MM slash DD slash YYYY Treatment Authorization By signing below and submitting this form, you authorize the veterinarians and staff of At Home Animal Clinic to examine, complete diagnostics, perform procedures, prescribe, and administer treatment as is considered medically necessary for your pet(s). Record Release Authorization To ensure continuation of care, At Home Animal Clinic will obtain your pet’s medical records and communicate with previous veterinary clinics that have provided care for your pet(s). At Home Animal Clinic may also release your pet(s)' medical information including vaccine history, medical records, diagnostic images, and lab work to other veterinary hospitals, boarding facilities, groomers, authorities, and pet insurance companies as necessary. By signing below and submitting this form, you acknowledge that At Home Animal Clinic will obtain your records from previous veterinary clinics and may release your pet’s records on request. Email & Text Messaging Communication Consent Clients of At Home Animal Clinic may receive direct conversational communication via email and/or text messaging from an employee representative to discuss a pet’s veterinary care, appointment scheduling, or billing. Clients may also receive automated informational communications via email and/or text messaging to be reminded of their pet’s upcoming appointments, veterinary care needs, surveys, and promotions. Messaging and data rates may apply. At Home Animal Clinic Clients may opt-out, unsubscribe, stop, or change their email and / or text message preferences at any time. May we contact you by text? Yes, I would like to receive text message communication. No, I opt out of text message communication. May we contact you by email? Yes, I would like to receive email communication. No, I opt out of email communication. Appointment Policy At Home Animal Clinic's Appointment Policy When clients repeatedly cancel, delay, or miss appointments it is detrimental to At Home Animal Clinic’s mission, and prevents other pets from receiving care. We ask that you give us the courtesy of a 6-hour notice if your appointment needs to be altered. If you are more than 10 minutes late for an appointment, we may need to reschedule your appointment. Clients that are chronically late, cancelling, or missing appointments may be asked for a deposit before scheduling future appointments. By signing below and submitting this form, you acknowledge that you have read and understand At Home Animal Clinic’s appointment policy. Payment Policy At Home Animal Clinic's Payment Policy Full payment is due at the time of service. At Home Animal Clinic accepts all major credit cards, cash, and checks. Payments made by card are subject to a 1.25% fee adjustment to offset the processing fees. Clients with payment concerns are asked to speak to a Client Service Representative prior to services being rendered. Payment plans are available through third party provider Care Credit. No other payment plans, or delayed billing are offered. By signing below and submitting this form, you acknowledge that you have read and understand At Home Animal Clinic’s payment policy. Your signature below indicates you have read and understand these policies.Signature(Required)Date(Required) MM slash DD slash YYYY If you do not hear from us withing the next business day, please call or text us at (651) 351-7387 or email firstname.lastname@example.org to follow-up on your new client submission.CommentsThis field is for validation purposes and should be left unchanged.