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 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 for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here


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