New Client Form

Client Information

How did you hear about our practice?

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)

Name of Previous Veterinarian

Previous Veterinarian Phone Number

Pet Information

Pet Name*

Pet Species*

Dog
Cat

Pet Gender*

Male
Female

Spayed/Neutered?*

Yes
No

Pet Breed*

Pet Color*

Pet Birthday or Approximate Age

Additional Pet?

Yes
No

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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We’re excited to see you!

Client Information

Pet Information

Get in touch

(847) 843-2226

Business Hours

(847) 843-2226