New Patient/New Client Form


New clients, please fill out the following form.



Pet Owner

* Owner First Name

* Owner Last Name

* Phone

* Ok to text?

* Email

Co-Owner

Co-Owner First Name

Co-Owner Last Name

Phone

Ok to text?

Email

Pet Owner Address?

* Street Address

Address Line 2

* City

* State

* Zip

How did you hear about us?

How did you hear about us?

If Other, please specify here

If personal referral, please specify here

Previous Veterinarian

Name

Phone

  First time seeing a veterinarian


Pet Information (Pet #1)

* Pet Name #1

* Pet Sex #1

* Pet Species #1

* Pet Breed #1

* Pet Color #1

* Pet Date of Birth or Pet Approximate Age #1

Pet Medical History #1

* Reason for scheduling #1

Previous History File (Pet #1)
Optionally attach your pet's previous history records here. Acceptable types are docx, pdf, jpg, jpeg, gif, png

Pet Image (Pet #1)
Optionally attach your pet's photo here. Acceptable types are jpg, jpeg, gif, png


Add Another Pet


Do you have a preferred appointment day?

  Monday
  Tuesday
  Wednesday
  Thursday
  Friday
  First Available

Do you have a preferred appointment time?

  Morning
  Afternoon
  Either

Agreements

If your pet is experiencing a medical emergency please call the office at (618) 622-3778. If this request is outside business hours please contact Animal Emergency Center in Collinsville, IL at (618) 346-1843

  Do we have permission to use your pet's picture, video or personal story for social media purposes

  * I understand that my deposit left at the time I schedule my appointment is nonrefundable if I do not follow the No Show/Cancellation Policy guidelines