Portage Park Animal Hospital & Dental Clinic New Client Form

Welcome to our Hospital! Please take a few minutes to tell us about you and your pet(s). You may fill out this form on your computer before printing, or submit it electronically.

For your first appointment, please bring medical history for your pet along with your photo id.
* Required fields for electronic submissions.

Owner Information

Last Name *    First Name    Title

Address    City    State      Zip

Home Phone       Cell       Alternate

E-mail Address*

Co-Owner Information


Last Name    First Name    Title

Address    City    State      Zip

Home Phone       Cell       Alternate

E-mail Address

Please tell us how you learned about us?

Friend/Relative      Who can we thank for this referral?  

Yellow Pages (Book)    Yellow Pages (Internet)

Web Site    Internet (Other)    Newspaper Ad    Pet Store    Clinic Sign

What day is your appointment?     

Patient #1 Information

Pet's Name        Species:    Dog        Cat        Rabbit        Other

Birthdate              Breed

 Color/Markings     

Intact Male       Neutered Male           Intact Female    Spayed Female

Previous Animal Hospital / Vet

Has your pet been vaccinated in the last year?    Yes        No      If yes, Date:   

Is your pet on parasite prevention?    Yes      No      If yes, please specify:

Does your pet have allergies?             Yes      No      If yes, please specify:

Any prior medical condition, illness or surgery?

Taking any special diets or medications?

Tell us what concerns you have about your pet:     Bad Breath      Coughing     Ear Problems      Not Eating

Diarrhea      Vomiting     Weight Gain or Loss      Itching/Scratching      Sores/Wounds      Lameness

Problems Getting Up      House Soiling     Behavior Changes      Separation Anxiety      Aggression

Other:


Patient #2 Information

Pet's Name        Species:    Dog        Cat        Rabbit        Other

Birthdate              Breed

 Color/Markings     

Intact Male       Neutered Male           Intact Female    Spayed Female

Previous Animal Hospital / Vet

Has your pet been vaccinated in the last year?    Yes        No      If yes, Date:   

Is your pet on parasite prevention?    Yes      No      If yes, please specify:

Does your pet have allergies?             Yes      No      If yes, please specify:

Any prior medical condition, illness or surgery?

Taking any special diets or medications?

Tell us what concerns you have about your pet:     Bad Breath      Coughing     Ear Problems      Not Eating

Diarrhea      Vomiting     Weight Gain or Loss      Itching/Scratching      Sores/Wounds      Lameness

Problems Getting Up      House Soiling     Behavior Changes      Separation Anxiety      Aggression

Other:

Financial Policy: Portage Park Animal Hospital requires payment in full for professional services when your pet is discharged from the hospital. For those who prefer payment plans or credit options, please click here www.carecredit.com

As legal owner or responsible agent of the above animal(s), I certify that I have read and agree to this financial policy. I hereby assume financial responsibility for all services rendered.

Owner/Agent       Date: