American Veterinary Hospital Yreka Veterinarian / New Client Form

201 Greenhorn Rd
Yreka, CA 96097
(530)842-5719

Fax:(530)842-7856

Hours of Operation

Monday 8:30am-5pm
Tuesday: 8:30am-5pm
Wednesday: 8:30am-5pm
Thursday 8:30am-5pm
Friday 8:30am-12pm

Closed 12pm-1:30pm daily

Patients seen by Appointment only.

Doctor may not be available for appointments during all posted hours.

For After Hours Emergency Please Call:

Southern Oregon Veterinary
Specialty Center
4901 Biddle Road
Central Point, OR
541-282-7711

American Veterinary Hospital

201 Greenhorn Rd
Yreka, CA 96097

(530)842-5719

www.americanveterinaryhospital.com

New Client Check In

If you would like to make an appointment please call our office at 530-842-5719 during normal business hours. You can assist us to expedite your check in by submitting this form prior to your appointment.

Thank you for your cooporation in allowing us to 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 Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :

Breed:

Color: (required)

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

Reasons or conditions that prompted your visit?

Special requests or conditions?

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