The Animal Hospital of Barrington New Client Form

Welcome to the Animal Hospital of Barrington

Client Information:
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following form entirely.
Guardian Name

First Name Last Name
Guardian Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Landline (Home Phone)

Area Code Phone Number
Cellphone

Area Code Phone Number
Email *
example@example.com
Please let us know your preferred method of contact.
Do we have permission to send vaccine and appointment reminders to your e-mail address?

Yes No
Driver's License Number (required if paying by check)
Pet Insurance Provider
Do we have permission to use your pet's images on our practice's social media pages?

Yes No
How did you become aware of our clinic?

Drove by Internet Personal recommendation
If a friend or family member recommended us to you, whom may we thank?

First Name Last Name

PET # 1

PET # 2

PET # 3

NAME

BREED

DATE OF BIRTH (mm/dd/yyyy)

COLOR

SEX

SPAYED / NEUTERED?

DOG OR CAT

Emergency Contact (other than yourself)

First Name Last Name
Emergency Contact Phone Number

Area Code Phone Number
Payment Policy:

A deposit is required on all surgical, dental and medical procedures. I hereby authorize the veterinarian to examine, prescribe for and treat the above described patient(s). I ASSUME FULL FINANCIAL RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF THIS PATIENT AND AGREE TO PAY IN FULL AT THE TIME SERVICES ARE RENDERED.
Signature

Clear
Should be Empty:

Welcome to the Animal Hospital of Barrington