Animal Hospital of McHenry - McHenry, IL - New Client Form

Animal Hospital of McHenry

4005 W Kane Ave. Suite C
McHenry, IL 60050

(815)385-7096

www.animalhospitalofmchenry.com

New Client Form

 

Thank you for trusting Animal Hospital of McHenry to care for your pet. So that we may become better acquainted, please complete the following form below. 

Please fill out another form for each additional pet you'd like us to see.

 

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
County (required)

Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months (required)

How long have you had your pet? (required)

Type of Pet (required) :
Breed: (required)

Pet's Color: (required)

Sex: (required)

Male, Neutered
Male
Female, Spayed
Female


Is your pet microchipped? (required)

Yes
No
Unsure


Are your pets vaccines current? (required)

My pets vaccines are current
My pets vaccines are NOT current


Do you have pet insurance for your pet?

Yes
No


Will this be your pet’s first vet visit? (required)

Yes
No
Unsure


On a scale of 1-5: Does your pet enjoy vet visits? (1 - I am very nervous and may need special accommodations for a successful visit, 5 - I love the vet and meeting new people!)

1
2
3
4
5


Do you have your pets medical records? (required)

Yes, I have my pets medical records
No, I do NOT have my pets medical records


Are your pets medical records at another veterinary practice?

Yes
No


Name of Former Veterinary Practice:

May we request a transfer of records?

Yes
No


Reason for changing veterinarians:

Would you like us to call you for your appointment?
Reasons or conditions that prompted your visit? (required)

Were you referred to us by anyone?

Are you interested in information about our Wellness Plans?

Yes
No


Special requests or conditions?

I understand that a $60 deposit is required when scheduling this first veterinary appointment, and that this cost will come off the total of the first visit bill.
Please list any additional pets here


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