Coulter Animal Hospital

5200 S. Coulter St
Amarillo, TX 79119

(806)353-6673

coulterah.com

New Client Form

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 cooperation.

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: (required)

Color: (required)

Sex: (required)
Male
Female


Neutered/Spayed (required)
Neutered
Spayed
Intact


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 Coulter Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Coulter Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



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CLINIC HOURS:

Monday - Friday

7:30 AM - 6:00 PM

Saturday

8:00 AM - 12:00 PM

(No grooming available)

Sunday

C L O S E D

(No boarding drop-off/pick-up)

EMERGENCY AFTER-HOURS CALL 806-353-6673 AND FOLLOW THE RECORDED PROMPTS

*

Appointments Preferred

    Call for Walk-In Policy     


ePet Health is a private website that gives you secure online access to your pet's health information. We provide this ePet Health site free of charge to all clients who have an active email address on file.