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. Title Mr. Mrs. Ms. Dr. Rev. Name* First Last Street Address*City*State*2 Letter state ID with no periods.Zip Code*Home Phone*Work Phone*Cell/Other Phone*Email Spouse/Co-Owner Name Prefix First Last Suffix Spouse/Co-Owner Work PhoneSpouse/Co-Owner Cell PhoneSpouse/Co-Owner Email Enter Email Confirm Email Are you a Senior Citizen (>65) or Member of the Military ?Senior CitizenMember of the MilitaryName 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 30days. By submitting this form you are accepting the terms of the above statement.*Agree Submit This iframe contains the logic required to handle AJAX powered Gravity Forms.