Ambassador Animal Hospital

510 Guido Circle
Bloomington, IL 61701

(309)662-8535

ambanhosp.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.

Thank you for choosing us for your pet's health care needs.

New Client

Name (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 :
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


Would you like us to call you to schedule an appointment?
Reasons or conditions that prompted your visit?

Please list any additional pets here

How did you hear about our hospital?

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 Ambassador Animal 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 billing charge of $5.00. Any balance that I leave unpaid will be forwarded to Ambassador Animal 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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