Request Appointment at Greenhaven Animal Clinic

New Client Form

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.

Download this New Client Form as a PDF, print it, fill it out and fax it to 309-247-3258

Fill out our New Client Form online:

Primary Owner

Full Name (First and Last Name):

Full Address (Street, City, State, Zip, County):

Employer:

Phone(Evening):

Driver´s License Number:

Social Security Number:

E-mail Address:


Spouse/Co-Owner

Full Name (First and Last Name):

Employer:

Phone(Daytime):

Phone(Evening):


Emergency Contact Information

Full Name (First and Last Name):

Phone(Daytime):

Please let us know how you heard about Greenhaven Animal Clinic

If you selected "Individual" please let us know who we may thank:

Notices

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.

Print Name:

Signature (You will sign your form when you come to our clinic)

Date:

Pet Information:

Pet#1 Information

Pet´s Name:

Date of Birth or Age:

Species (Dog, Cat, Other):

Breed:

Sex: (Male/Female) (Neutered/Spayed):

Color/Markings:

Vaccinations were given last by (clinic name):

Date of Last Vaccinations:

Allergies or Long-term Medical Problems:

Pet #2 Information

Pet´s Name:

Date of Birth or Age:

Species (Dog, Cat, Other):

Breed:

Sex: (Male/Female) (Neutered/Spayed):

Color/Markings:

Vaccinations were given last by (clinic name):

Date of Last Vaccinations:

Allergies or Long-term Medical Problems:

Pet #3 Information

Pet´s Name:

Date of Birth or Age:

Species (Dog, Cat, Other):

Breed:

Sex: (Male/Female) (Neutered/Spayed):

Color/Markings:

Vaccinations were given last by (clinic name):

Date of Last Vaccinations:

Allergies or Long-term Medical Problems:

Greenhaven Animal Clinic



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