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:

Name *(required)*

First Name (required)	Last Name (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone 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

Verify the reCAPTCHA: