New Client Check In

If you would like to set up an appointment to come to our clinic, please fill out this electronic form and submit it online. We will be in contact with you shortly after receiving your form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name & Email (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 (required) :
Pet's Name (required)

Birthdate:

Type of Pet (required) :
Breed: (required)

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Is your pet current on vaccines?
Yes
No
Unknown

Do you have your pet's medical records?
Yes
No

Name of Former Veterinary Practice and Phone Number

May we request a transfer of records?
Yes
No

Would you like us to call you to schedule an appointment?
Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at DuPage Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance.
I have read this statement and -
I Agree
I Disagree


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