Kingsbury Animal Hospital

420 North Skinker Blvd.
Saint Louis, MO 63130

(314)721-6251

www.kah.com

New Client Check In

If you would like to make an appointment, you can assist in expediting the process by filling out this form. 

We do ask that all new clients do the following:

  • Fill out our new client form(below)
  • Have your pets records sent to us. email:doc@kah.com or fax: 314.721.7513
  • Due to our current high volume of calls please allow us at least 1-3 business days and someone will call to schedule your appointment after receiving your form.
    • To best serve our clients we ask that all new clients pay a $55 reservation fee at the time of making their first appointment to hold your appointment time.
      The $55 comes off the cost of your appointment and is nonrefundable. You only have to do this for your first visit. (not required for groom only clients)

Thank you for your cooperation in letting us assist you.

New Client

CLIENT INFORMATION
Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Main Contact Number (required)
Phone TypePhone Number (required)
Secondary Contact Number
Phone TypePhone Number
WE COMMUNICATE FREQUENTLY VIA EMAIL. PLEASE BE SURE TO ENTER A VALID AND FREQUENTLY CHECKED EMAIL ADDRESS!
Your E-Mail Address (required) :
Employer

Spouse / Significant Other
First Name
Last Name
Spouse / Significant Other Cell Phone

How did you become aware of us?
Referred by name shown below

Drove by
Greater St. Louis Training Club
Internet
If Internet, what specific site?

Groomer Referral
Other source (please list below)

My preferred method of payment will be

cash
mastercard
visa
discover
CareCredit
Debit


PATIENT INFORMATION
Pet's Name (required)

Type of Pet (required) :
Breed: (required)

Color: (required)

Sex: (required)

Male
Female


Neutered/Spayed
(Choose this option only if your pet has already been spayed or neutered)

Neutered
Spayed


Age: Years, Months or Date of Birth (required)

Microchip Number:

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?

Yes
No


Name of Former Veterinary Practice

Phone Number of Former Veterinary Practice

Fax Number of Former Veterinary Practice


Please have your pet's prior records sent to us prior to your first visit. They can be dropped off or mailed to us at 420 N. Skinker, St. Louis MO 63130 or else faxed to us at (314)721-7513. Please ask that a cover sheet is included with any faxed records indicating that you are a new client.
Have you already made an appointment with us? If so, when is the appointment?

Reasons or conditions that prompted your visit?

Any previous serious illnesses or surgeries?

Any allergies to vacinations or medications ? (please list)

Is your pet on any special diet or medication?

Any special handling instructions / precautions we should be aware of when handling your pet?

I authorize Kingsbury Animal Hospital to photograph my pet(s) and use photos on social media networks or in our clinic. *This release will remain in effect until you notify us in writing of any desired changes.* (required)

I agree
I disagree


We will gladly prepare a written estimate upon request at any time. All fees are due at the time services are rendered. We accept all major credit cards, cash, and CareCredit. Do you agree? (required)

Yes
No


IMPORTANT!

To best serve our clients we ask that all new clients pay a $55 reservation fee at the time of making their first appointment to hold your appointment time. The $55 comes off the cost of your appointment and is nonrefundable. You only have to do this for your first visit. (not required for groom only clients)
Do you understand and agree to the above statements? (required)
Yes, I understand and agree

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