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:

 

New Client

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

Type of Pet (required) :
Breed:

Sex: (required)

Male
Female


Neutered/Spayed

Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?

Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No


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

Special requests or conditions?

Please list any additional pets here


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