Establishing a partnership for your pet's health

If you are an established client and have a new pet, please call our office to schedule an appointment. This page is intended for new/inactive clients only.

New clients are taken on a case-by-case basis. At times, waiting for a new client opening can be substantial--if you need to establish care in a timely manner, we encourage you to continue searching for other clinics and hospitals that are actively seeking new clients.

We are not able to guarantee a schedule opening for every person wishing to establish care for their pets at our clinic. If it is decided we can take you and your pets on, we will contact you to schedule once an opening becomes available. Priority will be given to owners with young pets needing to initiate their primary vaccination series, owners with newly obtained pets, and owners with adult pets who have a history of obtaining basic and regular preventive veterinary care.

After submitting this form, we may contact your current veterinarian (if you have one) to review your pet's medical record.

Thank you for your interest in our small independent practice!

Establishing a partnership for your pets health

Our clinics purpose is to build and preserve connections between you and your pet by providing preventive veterinary services with individualized care, compassion, and a commitment to excellence and service to others. Fulfillment of our mission requires partnership and trust between our clients and our care team. The first step in building this partnership is establishing an understanding of your pet's care history to see if we are best positioned to serve you. We aren't big on lots of paperwork--we are just hoping to nail down some basics before we schedule your pets first wellness exam.
Pet Owner Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Would like to establish care because*

Recently moved to the areaObtained a new pet and have not established care with a veterinarianHave established care with a veterinarian but would like to change clinicsOther
Who referred you to us?
Leave blank if not referred
Number of dogs/cats in my home*
My Pet(s)*
If the pet(s) listed above are adult animals and do not have a medical record established at another veterinarian, please explain the circumstances below.
As a potential client of Galesburg Veterinary Clinic, I understand and agree to the following clinic policies (please select each box to acknowledge)

All pet visits are appointment based only to ensure adequate time for each patient/clientA veterinarian-client-patient relationship (VCPR) is the basis for interaction among veterinarians, their clients, and their patients. An annual examination is needed to fulfill this legally defined relationship and is lawfully required for all prescriptions and medical advice.Payment is required at time of service unless other arrangements have been made in advance.The person who presents with their pet to an appointment must have authorization to make medical/financial decisions about the pet's care.In cases where needed care extends beyond the availability or capability of our practice you will be referred to a facility specially staffed and equipped for critical/advanced cases.Verbal harassment, abusive behavior, threats, and emotional blackmail are grounds for termination of services.
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Establishing a partnership for your pets health