New Client Information

With our convient online form, you can now make an appointment at any time, day or night, by just answering a few questions.

Simply fill out the required fields. Then, click "Submit" to send the form. A member of our team will contact you via email or phone, to confirm your appointment time.

Please note, your appointment is not confirmed until we notify you.
Location *
Client Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please enter a valid phone number: (###) ###-####
Primary Phone Type*
Please select your phone type
Email*
example@example.com
Pet Information
Pet's Name*
Pet's Age/Date of Birth*
Pet's Species*

DogCat
Pet: Is it an indoor or an outdoor pet?

IndoorOutdoorBoth
Pet's Breed*
Pet's Sex*
Pet's Color/Markings*
Reason for Appointment*

Previous Veterinarian
Previous Veterinarian Office Name
Location
Phone Number
Please enter a valid phone number: (###) ###-####
Do we have your permission to contact that veterinarian office to transfer your pet's records to our office?

YesNo

Referring Veterinarian
Primary/Referring Veterinarian
Hospital Name
Phone Number
Please enter a valid phone number: (###) ###-####
Please indicate any other veterinary specialists or primary care veterinarians your pet has seen in the last 12 months.
How many veterinary specialists would you like to list?

Specialist 1
Veterinary Specialist 1 practice name
Veterinary Specialist 1 Location
Veterinary Specialist 1 Phone Number
Please enter a valid phone number: (###) ###-####

Specialist 2
Veterinary Specialist 2 practice name
Veterinary Specialist 2 Location
Veterinary Specialist 2 Phone Number
Please enter a valid phone number: (###) ###-####

Specialist 3
Veterinary Specialist 3 practice name
Veterinary Specialist 3 Location
Veterinary Specialist 3 Phone Number
Please enter a valid phone number: (###) ###-####

Specialist 4
Veterinary Specialist 4 practice name
Veterinary Specialist 4 Location
Veterinary Specialist 4 Phone Number
Please enter a valid phone number: (###) ###-####

Specialist 5
Veterinary Specialist 5 practice name
Veterinary Specialist 5 Location
Veterinary Specialist 5 Phone Number
Please enter a valid phone number: (###) ###-####

I grant AVIM&O and its representatives and employees the right to take photographs of my pet and me. I authorize AVIM&O, its assigns and transferees to copyright, use and publish the same in print and/or electronically.*

YesNo
Printed Name for E-Signature*

First NameLast Name
Are you a robot?*
Should be Empty:

Client Information