If you do not yet have an appointment, please call The AMC at (212) 838-7053 to schedule one. Only fill out this form if you have an appointment scheduled with us.
After you have made your appointment and prior to your visit to The AMC, please fill out and submit the following information to us. Doing so will speed your visit, since we will already have your information and your pet’s information on file when you arrive. Fields marked with a red asterisk (*) are required.
This form should be used only if the pet has not previously registered at The AMC.
Note: The AMC does not release personal information to any third parties.

Client Information

 
* Title * First Name
(only one individual, please)		 M.I. * Last Name
Apt. * Street Address
* City * ST * ZIP + 4
* Home Phone Cell Phone 1 Cell Phone 2
() - () - () -
Email Address  
How did you hear about The AMC? If Other, please specify
 

Employment Information

 
* Your Status * If "Other", Specify * If Employed, Name of Employer
* Employer's Street Address
* City * ST * ZIP + 4
* Work Phone Extension * Your Position / Title
() -
 

How many pets will you be bringing to The AMC?

 

Pet #1 Information
 
* Pet Name * Species * If "Other", Please Specify
Breed * Color / Marking
* Sex * Spayed/Neutered Birthdate (MM/DD/YYYY)
/ /
Do you have other pets registered at The AMC? Y N
The AMC Doctor You'll See Reason for Visit
* Appt. Date (MM/DD/YYYY) * Appt. Time
/ /

Referring Vet's Name Referring Vet's Phone Number
() -
Referring Vet's Hospital Name
Referring Vet's Street Address
City ST ZIP + 4
 

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