Greenhaven Animal Clinic
30 US Highway 136San Jose, IL 62682
New Client Form
Please allow 24 hours for our staff to contact you regarding this New Client Form. If this is an emergency, or if your pet needs urgent care, please call us at 309-247-3231 for a faster response.
Full Name (First and Last Name):
Full Address (Street, City, State, Zip, County):
Driver´s License Number:
Social Security Number:
Please let us know how you heard about Greenhaven Animal Clinic
Facebook - Pinterest
Website - Internet
Pet Store - Humane Society
Other - Veterinarian
If you selected "Individual" please let us know who we may thank:
Payment is due at the time services are rendered. Balances not paid in full will be subject to additional collection fees and/or attorney fees incurred in the collection process. There is a $35 fee for returned checks.
Unless directed otherwise, Greenhaven Animal Clinic, its representatives and employees reserve the right to take photographs of clients and their pets, and to copyright, use and publish the same in print and/or electronically for the purpose of publicity, illustration, advertising and Web content.
Signature (You will sign your form when you come to our clinic)
Date of Birth or Age:
Species (Dog, Cat, Other):
Sex: (Male/Female) (Neutered/Spayed):
Vaccinations were given last by (clinic name):
Date of Last Vaccinations:
Allergies or Long-term Medical Problems: