New Client Form

Owner's Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Cell Phone
Email*
Do you have a spouse, significant other, or relative you would like to add to your chart?
- Spouse
- Significant Other
- Relative
- Other
Name of authorized person*
First Last
Phone number of authorized person*
Is this person authorized to release records to?*
- Yes
- No
How did you learn of our hospital?*
- Friend
- Drive By - I saw your sign
- Direct Mailer
- Rescue Group
- Animal Shelter
- Referring Veterinarian
- Facebook
- Google Search
- Website
Please provide us with your friend's name, so that we can thank them for their referral.*
Name*
Name*
Name of hospital*
Best way to contact you?*
- Phone
- Cell
- Email
- Text
Do you have pet insurance?
- Yes
- No
what type of pet insurance?*
Pet Information
Pet's Name*
Species*
Breed*
Color/Markings:*
Age or D.O.B.*
Sex*
- Male
- Female
- Spayed
- Neutered
Microchipped?*
- Yes
- No
Do you have a second pet?
- Yes
- No
Pet's Name*
Species*
Breed*
Color/Markings:*
Age or D.O.B.*
Sex*
- Male
- Female
- Spayed
- Neutered
Microchipped?*
- Yes
- No
Do you have a third pet?
- Yes
- No
Pet's Name*
Species*
Breed*
Color/Markings:*
Sex*
- Male
- Female
- Spayed
- Neutered
Age or D.O.B.*
Microchipped?*
- Yes
- No
Do you have a fourth pet?
- Yes
- No
Pet's Name*
Species*
Breed*
Color/Markings:*
Age or D.O.B.*
Sex*
- Male
- Female
- Spayed
- Neutered
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.
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.