New Client Form

Owner's Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell Phone
Home Phone
Work Phone
Email
Would you like to receive emails for your pet’s reminders?*
- Yes
- No
Others who we can release your pet and/or their info to:
Pet Information
Pet's Name
Sex
- Male
- Female
Age or D.O.B.
Date Format: MM slash DD slash YYYY
Species
Breed
Color/Markings:
Spayed/Neutered?
- Yes
- No
- Not sure
Microchipped?*
- Yes
- No
Do you have a second pet?
- Yes
- No
Pet's Name
Sex
- Male
- Female
Age or D.O.B.
Date Format: MM slash DD slash YYYY
Species
Breed
Color/Markings:
Spayed/Neutered?
- Yes
- No
- Not sure
Microchipped?*
- Yes
- No
Do you have a third pet?
- Yes
- No
Pet's Name
Sex
- Male
- Female
Age or D.O.B.
Date Format: MM slash DD slash YYYY
Species
Breed
Color/Markings:
Spayed/Neutered?
- Yes
- No
- Not sure
Microchipped?*
- Yes
- No
Do you have a fourth pet?
- Yes
- No
Pet's Name
Sex
- Male
- Female
Age or D.O.B.
Date Format: MM slash DD slash YYYY
Species
Breed
Color/Markings:
Spayed/Neutered?
- Yes
- No
- Not sure
Microchipped?*
- Yes
- No
Previous Vet
Previous Vet City and State
Previous Vet Phone
You and your pet are the most important visitor in our hospital. What is most important to you when choosing a veterinary hospital?
Why did you leave your previous vet?
I understand that pictures of my pet may be taken for his/her medical record. I do/ do not (Make a check box) give permission for the photos to be used in promotional material for the hospital.*
- Yes
- No
*
- I understand that payments are due at the time of service and that Hometown Veterinary Hospital does not extend credit.
ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. PLEASE INDICATE CHOICE OF PAYMENT:*
- Cash/Check
- Visa
- Mastercard
- Discover
- Care Credit
RECORD RELEASE: SOMETIMES BOARDING FACILITIES, GROOMERS, REFER RAL HOSPITALS, ETC. MAY REQUEST RECORDS TO BE FAXED. WE ARE ASKING AT THIS TIME FOR YOUR CONSENT TO DO SO IF REQUESTED.*
- Yes
- No
*
- I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, OR TREAT THE ABOVE-DESCRIBED PET(S). I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF THIS ANIMAL. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR TREATMENT.
How did you learn of our hospital?*
- Friend
- Drive By - I saw your sign
- Direct Mailer
- My apartment complex.
- Rescue Group
- Animal Shelter
- Yellow Pages
- Referring Veterinarian
- Event
- Online
Please provide us with your friend's name, so that we can thank them for their referral.*
Name*
Name*
Name*
Name of hospital*
Name of event*
If you found us online, please choose one of the following*
- Google Search
- Google Ads
- Google + page and reviews
- Yelp.com
- YP.com
- Our Website
- Facebook
- YouTube
Signature*

About Us

Hometown Veterinary Hospital is owned by Springfield natives Dr. Kara (Chappell) Amstutz and Dwight Amstutz. Our practice has continuously grown since it’s beginning in 2002 with each advancement focused to better serve our clients and their pets. We focus on being very transparent with our clients as we team with you to provide unparalleled care of your pets. Our motto says it all..Hometown Veterinary Hospital, Where Medicine and Mercy Meet.

Hours

Monday - Friday: 7am-5pm
(Thursdays closed 12pm-2pm for staff training)
Saturday: Closed
Sunday: Closed

After Hours Emergency

Emergency Veterinary Clinic of SW Missouri
400 S Glenstone Ave, Springfield, MO 65802
417-890-1600

Contact

417-883-7297
hometownvet@gmail.com

Location

2215 W. Republic Road
Springfield, Missouri 65807

Directions

Take Kansas Expressway South to Republic Road, turn right (west), we are at the 1st stop light on the northwest corner of Cox and Republic Road.