Veterinary Forms | Animal Clinic at New Lenox

Co-Owner Name (first & last):

Co-Owner Phone Number:

Would you like to receive e-reminders

yes

no

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Previous Veterinarian and Phone Number

How did you hear about us?

Internet Search

Drive By

Client Referral

Shelter

Event

Other

If you were referred by a client or shelter, can you please provide their name so we may thank them?

If you learned about us from an event, which event did you attend?

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

Reason for your pet's visit:

All professional fees are due at the time services are rendered and/or at the time of discharge. We will gladly prepare a written treatment plan of service fees if requested. Accepted payment methods are cash, debit card, major credit cards (American Express, Discover, Mastercard, Visa), and Care Credit. A $25.00 service charge will be incurred on any returned payment. I understand and agree that I am at least 18 years old, have read and understand the above terms, and hereby agree to abide by and adhere to these terms. Selecting "I agree" below authorizes the veterinarian to examine, prescribe for, and/or treat my pet(s).*

I agree

I do not agree

New Client Form