Ambassador Animal Hospital

510 Guido Circle
Bloomington, IL 61701

(309)662-8535

www.ambanhosp.com

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 choosing us for your pet's health care needs.

New Client

Name *(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 Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

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 to schedule an appointment?

Reasons or conditions that prompted your visit?

Please list any additional pets here

How did you hear about our hospital?

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The clinic will be closed on Monday and Tuesday, December 24 & 25, 2018 for the Christmas Holiday

The clinic will also be closed December 31 & January 1 for the New Year Holiday

HOURS

Day	Open	Close
Monday	7:30am	5:30pm
Tuesday	7:30am	5:30pm
Wednesday	7:30am	5:30pm
Thursday	7:30am	12:00pm
Friday	7:30am	5:30pm
Saturday	8:00am	12:00pm
Sunday	Closed	Closed

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