Animal Hospital of Lake Villa • New Client Form

New Client / Patient Form

Thank you for giving us the opportunity to care for your pet! Please help us meet your needs better by taking a moment to complete this form.

Have You Been to Our Clinic Before?

Yes
No

Name

First

Last

Phone

For quality and training purposes all phone calls are recorded.

Is This a Cell Phone?

Yes
No

Would You Like To Add a Secondary Phone?

Yes
No

Secondary Phone

For quality and training purposes all phone calls are recorded.

Spouse / Other

First

Last

Leave blank if non-applicable

Spouse's Phone

For quality and training purposes all phone calls are recorded. Leave blank if non-applicable.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Pet Name

Pet Age or Date of Birth

Breed

Color(s)

Sex

Are They Microchipped?

Yes
No
Unsure

Do You Know The Number?

Yes
No

Microchip Number

Add Another Pet?

Yes
No

Pet Name

Pet Age or Date of Birth

Breed

Color(s)

Sex

Are They Microchipped?

Yes
No
Unsure

Do You Know The Number?

Yes
No

Microchip Number

Add a 3rd Pet?

Yes
No

Pet Name

Pet Age or Date of Birth

Breed

Color(s)

Sex

Are They Microchipped?

Yes
No
Unsure

Do You Know The Number?

Yes
No

Microchip Number

Are You Able to Attach Past Records For Any Above Listed Pets?

Yes
No

If No, Is There Somewhere We Can Call For Records?

Type "No previous history" if, to your knowledge, the pet hasn't been seen by a veterinarian.

First and Last Name Records Are Under if Different Than Yours.

Use this if you recently obtained pet from a previous owner.

Attach Form(s) Below

Click or drag files to this area to upload. You can upload up to 4 files.

Additional Information That May Be Useful

How Did You Hear About Our Animal Hospital?

Who can we thank?

If Other, Please Explain

Marketing Release: Can We Use Pictures of Your Pet on Our Hospital Social Media Pages?

Yes
No

Disclaimer

I authorize the doctor to provide vaccines and parasite control as needed for my pet. I assume responsibility for all charges incurred in the care of this (these) animal(s). I also understand that these charges will be paid at the time of release unless prior arrangements have been made. A deposit may be required for inpatient procedures at the discretion of the Animal Hospital of Lake Villa. I agree to pay all outstanding balances together with any other charges (finance and/or collection) due thereon. I understand that personal checks are not accepted as a form of payment and I will provide payment in the form of Cash, Care Credit, Scratchpay, Visa, Mastercard, American Express, Discover, or debit cards.

Signature

Clear Signature