NEW CLIENTS: PLEASE FILL OUT INFORMATION BELOW
Please provide the information below as completely as possible. All information is strictly confidential.
Owner Information
Last Name *
First Name *
Street Address *
City *
State *
Zip Code *
Phone *
Is this number *
HomeCellWork
Can we send text reminders to this cell phone? *
YesNo
Email *
Co-Owner Information (optional)
Last Name
First Name
Phone
Is this number
HomeCellWork
Can we send text reminders to this cell phone?
YesNo
Patient Information
Pet's Name *
Type of Pet *
DogCatRabbitOther
Gender *
MaleFemale
Spayed / Neutered? *
YesNoUnknown
Age (years or months) / Birthdate (xx/xx/xx) *
Breed *
Color / Markings *
Where has your pet been taken before for shots or illness?*
Please upload any previous medical records you have:
Do you already have an appointment scheduled? *
YesNo
If "Yes", when is it scheduled for?
Please share if your pet has a social media account
If you have additional pets you'd like to add, we can complete that at your first appointment.
Parking at our clinic
Please note, there is a "Loading Zone" in front of our clinic. You are welcome to park here during your visit. This parking area is designated for Portage Park Animal Hospital clients only.
Social Media Policy
I hereby grant Portage Park Animal Hospital permission to take photographs of my pet and/or myself, and to publish those photographs for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. I also grant permission to use my pet’s name.
If you’d like to OPT OUT, please check here.
OPT OUT
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 visit www.carecredit.com.
By checking below you certify that you are the owner of the above pet, have the authorization to consent to treatment if and when it is needed and are assuming financial responsibilities for all services rendered.
Confirmation *
I Agree
