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New Client Registration Form

Your Pronouns:

Significant Others Name:

Significant Others Pronouns:

Date of upcoming appointment:

How did you hear about us?

Emergency Contact:

In case of an Emergency please contact (Person different than listed above):

Name:
Phone Number:

Patient Information:

Patient Name(s):

Breed(s) Specify:

Age(s) / Birthdate(s):

Color(s):

Sex(s):

Neutered:

Yes

No

Previous Veterinarian / Animal Hospital:

Please list any prior illness/diseases/medications:

I hereby authorize the staff at Animal House of Chicago to take and share photo images of my pet for use on the clinic social media pages.*

I authorize

I do not authorize

I understand that if I order medication through an internet pharmacy, that Animal House of Chicago and the manufacturer are not responsible or liable for the condition of the product nor any adverse effects as a result of the products ordered or product failure. I understand that my pet must be current on exam in order for Animal House of Chicago to approve prescriptions. *

I understand

Professional Fees are due at the time services are rendered.

I understand and acknowledge my responsibility as the owner or caretaker of this animal and agree to pay for all charges incurred during the treatment and or care of this animal at the time services are rendered. I understand that outstanding balances have interest charges (up to 2%) and fees, including ALL collection costs.

If appropriate to the species & to prevent the spread of infectious diseases, hospitalized and/or boarding animals must be current on ALL vaccines and free of internal and external parasites. I understand this requirement and authorize the doctor to provide vaccines and parasite control as needed for my pet(s). I am aware that unforeseen events resulting from treatments, procedures, hospitalization, et cetera will not relieve me of my complete financial obligation to all costs incurred regarding the complete care of my pet.*

Signature:
Today's Date: