Animal Wellness Center

Loving Care for the Lifetime of your Pet 

West Palm Beach Office
10337 Southern Blvd
Royal Palm Beach, FL 33411
(561) 790-3555





Fort Lauderdale Office
2372 N. Federal Hwy
Fort Lauderdale, FL 33305
(954) 537-3505

 

 

 

 
 

 

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - 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 (required)

Type of Pet (required) :
Breed:

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

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

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Animal Wellness Center and that charges are due and payable at the time of service. Animal Wellness Center does not provide payment plans or billing options. We accept cash, local checks with a valid Florida Driver's license, debit cards, VISA, Mastercard, American Express & Discover. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. A fee of $30 will be charged on all checks returned by the bank.
I have read this statement and -
I Agree
I Disagree


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