New Client Form

We’re excited to see you!

Before your first visit, be sure to complete your New Client Form. If you need immediate assistance, please call us at 847-843-2226.

"*" indicates required fields

Client Information

How did you hear about our practice?

Coupon

Drive By

Phonebook

Online

Other

Referral

Name*

First

Last

Email*

Address*

Street Address

Address Line 2

City

State

ZIP Code

County

Driver's License #

Primary Phone*

Secondary Phone

Employer

Date of Appointment (if already scheduled)

MM slash DD slash YYYY

Name of Previous Veterinarian

Previous Veterinarian Phone Number

Pet Information

Pet Name*

Pet Species*

Dog

Cat

Other

Pet Gender*

Male

Female

Spayed/Neutered?*

Yes

Pet Breed*

Pet Color*

Pet Birthday or Approximate Age

Additional Pet?

Yes

Please upload any relevant pet records here

Max. file size: 50 MB.

At Animal Care Clinic, we continually strive to provide the highest quality services through a responsive, professional staff with emphasis on individual attention and commitment to excellence in animal health care.

PAYMENT IN FULL IS DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. For your convenience, we accept cash, checks, major bankcards (Visa, Mastercard, Discover) and Care Credit as forms of payment.*

I have read and understand.

The above listed customer agrees, by signing this authorization, to pay interest at the rate of 1.50% per month, which is the annual percentage rate of 18% on any past due account, and to pay the reasonable attorney's fees and court costs of Animal Care Clinic that are incurred in the collection of any past due account.*

I have read and understand.

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