New Client Form

Are you a new client to our practice? You can fill out your New Client Registration form securely online by filling in the form below.

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet’s before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 603-441-5776 for a faster response.

Are you a new client to our practice?

You can fill out your New Client Registration form securely online by filling in the form below.

All questions with an asterisk * after the question require an answer for this form to be submitted properly.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Cell / Other Phone

I consent to receive SMS text messages from Plaistow-Kingston Animal Medical Center. Msg & data rates may apply. Reply STOP to opt-out. *

Email *

Spouse / Co-Owner Name

Spouse / Co-Owner Work Phone

Spouse / Co-Owner Cell Phone

Spouse / Co-Owner Email

Confirm Email

Are you a Senior Citizen (>65) or Member of the Military ?

Senior Citizen
Member of the Military

Name of previous veterinarian or hospital so we can request records.

We accept Cash, Check, Credit Cards, Debit, CareCredit.

Informed Consent: I will assume full responsibility for all charges incurred in the care of this pet. I understand that FULL PAYMENT IS DUE WHEN SERVICES ARE RENDERED and that a DEPOSIT IS REQUIRED FOR ANY HOSPITALIZED OR BOARDED PET. If full payment is not made as required, Plaistow-Kingston Animal Medical Center has my permission to obtain credit information from an authorized agency to aid in collections. 1.5% Monthly Finance charge and $4.00/month billing over 30 days.

By submitting this form you are accepting the terms of the above statement. *

Agree

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New Client Form

New Client Form

We accept Cash, Check, Credit Cards, Debit, CareCredit.

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