Client Registration Form

Client Registration Form

Thank you for giving us the opportunity to care for your pet!
Please note that only the individuals listed as the primary and secondary owners on these forms are authorized to make changes to the account. They are also the only ones permitted to bring the pet in for services, pick up medications, or modify any treatment options. If the secondary owner makes changes, they will be recognized and confirmed in our system as an owner.
Owner #1*

First NameLast Name
Co-Owner/Spouse/Partner

First NameLast Name
Owner Cell Phone*
Please enter a valid phone number.
Owner E-mail Address*
example@example.com
Secondary Number
Please enter a valid phone number.
Secondary E-Mail Address
example@example.com
Owner Birthday*

MonthDayYear
Co-Owner Birthday

MonthDayYear
Drivers License Number*
THIS IS REQUIRED IN ORDER TO RECEIVE SERVICES
Drivers License Expiration Date*

MonthDayYear
In case of EMERGENCY, CALL First Name Last Name at Phone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Did You Hear About Us?*
If Another Hospital or Friend Referred You, Please Write The Name. If neither, write N/A*

Client Payment Options
For new clients, we require a booking fee, which covers your pet's office exam. Please note that if you cancel or reschedule your appointment less than 24 hours in advance, the booking fee will be forfeited, and a new fee will be required to reschedule. This booking fee may also apply to our current clients if they cancel or reschedule an appointment more than twice with less than 24 hours' notice.

Thank you for the opportunity to help you meet your pet's healthcare needs. Following is a list of the numerous payment options we accept. Please select your form of payment and provide all the required information. We do not offer financing or regular/recurring payment plan options directly through our office.

ALL PAYMENTS ARE DUE IN FULL AT THE TIME OF SERVICE

Payment Options: DRIVERS LICENSE OR CURRENT ID is required when paying with a credit card, CareCredit, All Pet Card or Scratchpay. Animal Medical Center of Corona will NO LONGER be accepting checks as a form of payment, Apple Pay, Google Pay, or another other form of digital payment. We also do not accept Pre-Paid cards.
- Cash
- Visa®, MasterCard®, American Express®, Discover Card®
- CareCredit® Payment Plan¹ *Allows you to begin treatment today and pay overtime*
  - ¹Subject to credit approval. Please see CareCredit Plan Selection Slip for additional terms and conditions.
    Please ask for an application or apply online at CARECREDIT.COM
    (This is a credit card you may apply for through CareCredit® that we accept as payment.
  - Instant Care Credit application, apply here at Animal Medical Center of Corona just ask an AMC staff
    member and apply today
- SCRATCHPAY- Get care now, pay later!
  Text PAY to 213-296-0817 or visit www.scratchpay.com
- All Pet Card (you can visit their website at www.allpet.com)
DEPOSIT: For treatments or healthcare plans requiring comprehensive care, hospitalized treatments or surgery will require a 100% DEPOSIT of the estimated low end to begin your pet’s medical treatment.

EMERGENCY VISITS WILL REQUIRE A $500 DEPOSIT. This will go towards your entire bill

PET INSURANCE: For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance.

ESTIMATES /MEDICAL CARE PLAN: We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at time services are rendered.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By signing below, you agree to the foregoing terms of payment:
Owners Name*

First NameLast Name
Owner Signature *

Clear

Animal Medical History

Please enter your pets details below.
Pet #1 Information
Has your pet been seen at any other hospital?*

YesNo
Name Of Hospital Your Pet Was Seen At Previously? If None, Write N/A*
If your pet has been seen at another veterinary hospital, it is essential for you to contact that hospital and request that your pet's medical records be sent either to yourself or directly to our hospital at customer.contact@amccorona.com.

Having complete and accurate medical history is crucial for us to provide the best possible care and accurate diagnosis for your pet. Without access to all previous medical records, our ability to diagnose and treat your pet effectively is significantly compromised and WILL require repeat services at YOUR expense.

Thank you for your cooperation and understanding.
Medical Records From Prior Hospital (REQUIRED IF SEEN ELSEWHERE) If Not Attached, We Will Require You To Call Prior To Being Seen)

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Snap a picture of your pet so we can add it to their chart!
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Pet #2 Information
Snap a picture of your pet so we can add it to their chart!
Cancelof
Pet #3 Information
Snap a picture of your pet so we can add it to their chart!
Cancelof
DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can be updated at the time of your appointment if it is not current.
I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize the staff at AMCC to receive, prescribe for, treat or perform surgery upon the pet(s) listed on the animal medical history form and additional pets I present. I understand that NO guarantees or assurances can be made as to the outcome or results obtained from any examination or medical treatment provided. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet within 5 days of the discharge date and do not notify AMCC within that time period, AMCC may assume that my pet is abandoned and are hereby authorized to deal with appropriate care of my pet as AMCC deems best and/or necessary
Animal Medical Center of Corona may at times take photos of your pet or use medical information for teaching purposes, veterinary literature and possibly hospital promotions. I authorize the release of photos or medical information for such purposes. Client confidentiality (Names and Personal Information) will be maintained.*
Furthermore, I am over 18 years of age and I agree to pay fees for services rendered at the time services are performed or when the pet is discharged from the hospital or the service is otherwise terminated. I further understand that if it is necessary to send my account to collection, I will be responsible for any collection fees, legal and/or court costs.
Signature*

Clear
Date*

MonthDayYear
Created: 05/2024 ~ BRL

Respectful Engagement Policy

Please read below very carefully
We wanted to take a moment to express our heartfelt gratitude for choosing Animal Medical Center of Corona as your trusted partner in your pet's healthcare journey. It's a privilage to be entrusted with the well-being of your beloved furry, scaley, and feathery family members, and we cherish the opportunity to serve you.

At Animal Medical Center of Corona, we are commited to providing modern medicine with old fashion care. We believe in fostering meaningful bonds, not only with our animal patients, but also with their devoted owners. These connnections are the cornerstone of our practice, and we treasure each and every one of them.
However, we recognize that none of this would be possible without the dedication and hard work of our exceptional staff members. From our friendly receptionists to our compassionate kennel techs, from our skilled technicians to our experienced doctors, each member of our team plays a crucial role in delivering the highest standard of care.

We hold our staff in the highest regard and insist on maintaning a culture of respect and appreciation within our practice. Anything less then the utmost respect for our staff and clients alike, will NOT be tolerated. Our staff is the heartbeat of our clinic and their unwavering commitment to excellence ensures that your pet receives the exceptional care they deserve.

We recognize that bringing your pet to our practice can be an emotionally charged experience, often accompanied by stress. Our dedicated staff is here to support you during these moments, providing a compassionate shoulder to lean on when times get tough.

By signing below, you acknowledge your commitment to respecting our staff and treating them with the same care and consideration you would expect for yourself and your pets. You agree not to engage in yelling, using inappropriate language, or causing harm to our staff in any manner which also includes rude behavior.

Our goal is to ensure you are always treated with respect as well. Our staff will never raise their voice, use offensive language, or harm you in any way. If this ever happens, please inform our office manager immediately.
Should such behavior occur towards our staff members, you will receive one warning and it will be documented in your medical records. Should a repeat incident happen, your pet's medical records will be printed, your account deactivated, and the veterinarian-client-patient (V.C.P) relationship terminated.
I, First Name* Last Name* agree to never disrespect the staff at Animal Medical Center of Corona. I understand that raising my voice, using inappropriate language, or causing harm to any staff member is not tolerated.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Pet's Name*
BRL 02/2025
Should be Empty:

Client Registration Form

Client Payment Options

Animal Medical History

Respectful Engagement Policy