Mark’s New Client Form Test

    Client Information

    Owner #1

    Last Name:

    First Name:

     

    Owner #2

    Last Name:

    First Name:

     

    Street:

    City:

    Zip:

    County:

    Primary Phone:

    Secondary Phone:

    Owner #2 Phone:

    Email:

    Preferred Communication

    Permission to use (pictures), (history) or (medical info) about your pets in the media? (our website, print materials, social media)

    Previous vet:

    Phone:

    Date of last vet visit:

    Reason for changing vets:

    How did you hear about us?:

    If referred by a friend, who?:


    Patient info:

    Pet #1 Name:

     

     

    Breed:

    Color:

    Date of Birth:

    Sex:

    Spayed/Neutered:

    Microchipped:

    Known medical Conditions:




    Pet #2 Name:

     

     

    Breed:

    Color:

    Date of Birth:

    Sex:

    Spayed/Neutered:

    Microchipped:

    Known medical Conditions:

     

    Reason for requesting 1st visit (routine vxn, illness, injury etc.)


    Payment Policy:

    A non-refundable deposit of $60 is required at the time of scheduling for all new client appointments. This deposit will be deducted from your total charges for your first visit. Deposits may also be required for major/surgical cases, trauma cases
    and emergency work where hospitalization is required. Full payment is expected upon rendering of our services, deferred payments and payment plans are not offered. We accept and provide information about CARE credit upon request. There is a fee
    for refunded checks. Outstanding balances are subject to additional fees and may result in account information being sent to a collections agency.

    Check to confirm submission.

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      • Jennifer P.Jennifer P.

        Love this animal hospital. Very friendly staff and the doctor doesn't rush with you and your fur baby. Read More

      • Monika N.Monika N.

        We spent many years with another animal hospital in McHenry. But when the time came to put our doggy down, our vet put us off another day, delaying her pain... Read More

      • V R.V R.

        I have used a number of vets over my lifetime and Dr. Schmidt ranks among the best of them. I get good explanations of what's going on with my dogs and... Read More