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. 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 This iframe contains the logic required to handle AJAX powered Gravity Forms.
Request an Appointment
Request an Appointment