New Client Form

If you’re a new client, please fill out this form.

Thank you for your interest in becoming a client of Advanced Animal Care! Due to a high volume of new client requests it may take us up to 7 days to contact you. If your pet has an urgent medical concern that cannot wait, please call 928-770-4918 as soon as you fill out this form.

Checkboxes *

I understand that due to a high volume of no show appointments, Advanced Animal Care requires a deposit of $50.00 for new clients on their first scheduled appointment.
I understand that if I am more than ten minutes late, miss, or cancel my first scheduled appointment without 24 hours notice, my deposit is forfeit and I will need to provide a new deposit to schedule future appointments.

We pride ourselves in offering high quality medical care to our patients while focusing on preventative medicine. We look forward to serving you and caring for your pets for years to come. Please fill out all the information on this form for accuracy. You must be 18 years or older to obtain a client relationship with us.

Name *

First

Last

Spouse/Secondary on account:

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Call Number *

Email Address *

Previous Veterinarian Hospital *

1st Pet's Name *

Species *

Dog
Cat
Other

Breed *

Color(s) *

Sex *

Male
Female

Spayed/Neutered *

How old/Date of Birth *

Health Conditions *

2nd Pet's Name

Species

Dog
Cat
Other

Breed

Color(s)

Sex

Male
Female

Spayed/Neutered

How old/Date of Birth

Health Conditions

3rd Pet's Name

Species

Dog
Cat
Other

Breed

Color(s)

Sex

Male
Female

Spayed/Neutered

How old/Date of Birth

Health Conditions

Upload Medical Records

Click or drag files to this area to upload. You can upload up to 10 files.

Medical Authorization and Financial Information 

I hereby authorize the doctor and assistants to administer treatment as is considered therapeutically and/or diagnostically necessary. I authorize medical treatment, as well as possible alternate modes of treatment which are explained to me by the medical staff. Patient confidentiality will be maintained. I authorize images of my pet(s) to be used in social media or for educational purposes. I assume financial responsibility for all charges incurred to the patient. I further understand that if I fail to pay the entire amount, I will be responsible for all attorney's and collection costs incurred for the purpose of collection. I hereby certify that I have read and fully understand the above authorization. Balances due over 30 days will be charged a 1.5% per month interest charge (24% APR) and a monthly billing fee of $5.00. Additional collection fees will be charged if your past due account is sent to collections. *

I have read and understand

We do not accept personal checks. We accept CareCredit and Scratchpay, but do not offer payment plans. *

I have read and understand

Cancellation Policy for Established Clients

Due to an increase in last minute cancellations and missed appointments, we have instated a new cancellation policy for existing clients. If we do not hear from an established client 10 minutes into their scheduled appointment start time it is considered a missed appointment. We require 24 hour notice for cancellation of an appointment. The first time an established client misses their appointment or cancels without 24 hour notice - It's on us - we all get busy! If an established client has this happen a second time within a 12 month period they will need to prepay for future appointments. This means leaving a deposit of either an examination fee or 50% of their surgical procedure's estimated cost on their account. If a client misses or cancels a prepaid appointment without 24 hour notice their deposit will be forfeit and their deposit will not be refunded. Multiple "no shows" in any 12 month period may result in termination from our practice. *

I have read and understand

By typing my name below I certify that all information is true and correct to the best of my knowledge. *

First

Last

Date *

Website

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