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Name *

First

Last

Has Your Address Changed Since Your Last Visit? *

Yes
No
1st Visit Here

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email

Vehicle Make, Model, Color *

Would You Like to Remain Curbside Today? *

Yes
No

Our lobby is CLOSED. Curbside or not, we will come outside and escort you into a room if you choose to come inside with your pet.

Are There Any Peanut Allergies in Your Household? *

Yes
No

For canine patients, we may use peanut butter to help win your pet over as a part of our Fear Free approach.

How many pets are you bringing today? *

1
2
3
4

Pet's Name *

Species? *

Microchipped? *

Yes
No

Do you know the microchip number? *

Yes
No

Microchip number? *

2nd Pet's Name *

Species? *

Microchipped? *

Yes
No

Do you know the microchip number? *

Yes
No

Microchip number? *

3rd Pet's Name *

Species? *

Microchipped? *

Yes
No

Do you know the microchip number? *

Yes
No

Microchip number? *

4th Pet's Name *

Species? *

Microchipped? *

Yes
No

Do you know the microchip number? *

Yes
No

Microchip number? *

Do you have insurance for your pet(s)? *

Yes
No

If Yes, Who is the Provider? *

Trupanion, Embrace, Lemonade, Nationwide, Etc.

Reason For Visit *

Wellness / Vaccines
Puppy / Kitten Exam
Coughing / Sneezing
Dermatology (Skin Issues)
Diarrhea
Ears
Eyes
Limping
Recheck For Previous Visit
Seizure Activity
Vomiting
Urinary
Other

Check all that apply

Has your pet(s) been anywhere recently, such as a groomer, boarding facility? *

Please Provide Detailed Information About Your Pets Visit. *

How long has the issue been going on, any symptoms your pet is experiencing, etc.

Is Your Pet On Any Medications and/or Preventions Currently? *

Yes
No

EX: Ostimax, Apoquel, Heartgard, Simparica TRIO

If Yes, Which Pet and Which Medications? *

Please list all pets, medications, strength, and dosing, to the best of your knowledge. Separate multiple medications with a comma(,)

Do You Need a Refill? *

Yes
No

Dog Handling Release *

I understand that Animal Hospital of Lake Villa requires that I bring my dog on a leash using a properly fitting collar or harness. I have been informed that Animal Hospital of Lake Villa has a double leash policy and as such, they will place an additional slip lead on my dog. I have been informed that this is done for the safety of my pet as Animal Hospital of Lake Villa is off of two busy roads. I have been informed that it is recommended that I step out of my vehicle, and hand the leashes over to the technician rather than opening the doors to let my dog out. I release Animal Hospital of Lake Villa and it's team members from responsibility should I not follow these guidelines described to me and let my dog loose.

Cat Carrier Release *

I understand that Animal Hospital of Lake Villa requires that I bring my cat in a properly working carrier. I have been informed that Animal Hospital of Lake Villa is happy to rent out a carrier should we need it. I release Animal Hospital of Lake Villa and their team members from responsibility should I decide otherwise and my cat run away from my failure to bring him/her/them in an appropriate pet carrier.

Any Other Information You May Have for the Doctor?

Do You Have Any Files to Upload Pertaining to This Appointment?

Click or drag a file to this area to upload.

EX: Pictures, previous history or blank insurance forms, etc.

If We Take Pictures Today, May We Use Them For Our Own Social Media or Marketing? *

Yes
No

Payment Options *

The undersigned also understands that all services are to be paid in total when the pet(s) is/are discharged unless prior arrangements are made. The owner or agent promises to pay such total, together with any other charges, finance and/or collection, due thereon. A written estimate will be furnished upon request. Forms of payment accepted include Cash, Mastercard, Visa, American Express, Discover, ScratchPay, or Care Credit. Personal checks are not accepted as a form of payment.

Signature *

Clear Signature

Animal Hospital of Lake Villa
101 S. Milwaukee Ave.
Lake Villa, IL 60046

Phone: (847) 356-8387
Text: (847) 356-8387
Fax: (847) 558-2606

Premier Veterinary Group
Emergency: (847) 548-5300

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