New Client Form

New Client Form, ALL information must be complete and ALL records emailed before an appointment can be made. By submitting this form, you are confirming you are 18 years or older and able to make any and all decisions regarding pets medical care. Payment is due in full at time of services. Pets brought in by anyone other then the listed on this form, will be responsible for payment and the "Owner or Co-owner" must call to approve additional decision makers to be added to account.
Owner Name

First NameLast Name
Co-Owner/Spouse/Significant Other/Family Member
Owner Cell Phone Number
Please enter a valid phone number.
Phone Home Phone Number :
Please enter a valid phone number.
Co-owner/Secondary Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County does the pet reside? ie Cook, Will, DuPage etc.
Is your pet a cat or a dog?
Pets Name:
Your pets age or date of birth:
Pet's Breed:
Pet's Color:
Pet's Sex M or F
Is your pet spayed or neutered?
Reason for visit:
Previous Vet:
By submitting this form, I authorize The Veterinary Clinic of Tinley Park to care for my animal. I understand payment is due at the time services are rendered.

If I am unable to make my scheduled appointment time, I will be charged a $25 cancellation fee on my account, if not cancelled within 24 hours.
Should be Empty: