Dog/Cat New Client Form

Dog/Cat New Client Form

Dog/Cat New Client Form

Dog/Cat New Client Form

Dog/Cat New Client Form

Dog/Cat New Client Form


Owner/Agent Name

Address

City

State

Zip

Home Phone

Cell Phone

Co-Owner

Cell Phone

Pet No 1

Pet Name

BIrthdate

Species

Breed

Color

Sex

Is your pet microchipped?

Current Medication(s)?

Pet No 2

Pet Name

BIrthdate

Species

Breed

Color

Sex

Is your pet microchipped?

Current Medication(s)?

How did you hear about us?


​​​​​​​We will gladly prepare a formal estimate if you desire. Please ask a patient care coordinator should you choose to request one. FULL PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. A deposit may be required for surgery or hospitalization upon admittance. A billing charge of 1.5% per month (18% per annum) will be charged on all accounts after the first thirty (30) days. ANY CHECKS RETURNED FOR INSUFFICIENT FUNDS, ETC, WILL HAVE A $25.OO FEE APPLIED. To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the doctor to provide vaccines and parasite control as needed for my pet.

I, undersigned, assume financial responsibility for all charges incurred, and agree to pay all such charges at the time services are rendered ar as arranged prior to an examination and/or treatment.


Owner/Agent Signature

Date

Contact Info


Address: 1214 W Park Ave
Libertyville, IL 60048
Get Directions
Phone: (847) 549-8500
Fax: (847) 549-0661
8475490661