"*" indicates required fields

Owner and Contact Information

Owner's First Name*

Owner's Last Name*

Co-Owner's First Name

Co-Owner's Last Name

Address*

Street Address

Address Line 2

City

State

ZIP Code

Primary Phone Number*

Email*

Pet Information

Pet's Name*

DOB / Age*

Estimate if needed

Species*

Cat

Dog

Other

If other, please specify*

Breed*

Color*

Gender*

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?*

Yes

If yes, please specify*

Do you have your pet's medical records?*

Yes

Are your pet's medical records at another veterinary practice?*

Yes

Name of former veterinarian practice*

City / State of former practice*

May we call to request a copy of records before your visit with us?*

Yes

Reason for your visit*

Special requests or conditions

Would you like to add a second pet?*

Yes

Second Pet Information

Pet's Name*

DOB / Age*

Estimate if needed

Species*

Cat

Dog

Other

If other, please specify*

Breed*

Color*

Gender*

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?*

Yes

If yes, please specify*

Do you have your pet's medical records?*

Yes

Are your pet's medical records at another veterinary practice?*

Yes

Name of former veterinarian practice*

City / State of former practice*

May we call to request a copy of records before your visit with us?*

Yes

Reason for your visit*

Special requests or conditions

Would you like to add a third pet?*

Yes

Third Pet Information

Pet's Name*

DOB / Age*

Estimate if needed

Species*

Dog

Cat

Other

If other, please specify*

Breed*

Color*

Gender*

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?*

Yes

If yes, please specify*

Do you have your pet's medical records?*

Yes

Are your pet's medical records at another veterinary practice?*

Yes

Name of former veterinarian practice*

City/State of former practice*

May we call to request a copy of records before your visit with us?*

Yes

Reason for your visit*

Special requests or conditions

Emergency Contact Information

Emergency Contact First Name*

Emergency Contact Last Name*

Emergency Contact Phone Number*

More Information

How did you hear about us?*

Street Sign / Location

Google / Yahoo

Yelp

Public Event

Mailing

Petland

Facebook

Yellow Pages

Have been here before

Shelter / Rescue

Referred by a friend

Referred by groomer, employee, or other

Other

Who can we thank for the referral?*

Photography Consent: I grant to Companion Animal Hospital, its representatives and employees, the right to take photographs of me, and/or my pets, or my designated agents for publish in print and/or to use electronically. I agree that Companion Animal Hospital, its representatives and employees may use such photographs for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.*

I Agree

I Disagree

Terms of Service

I assume responsibility for all charges incurred in the care of this pet brought in by myself or another individual. PAYMENT IN FULL is required at the time services are rendered. We do not offer any form of billing. I understand that a treatment plan providing the details and costs for the anticipated veterinary services will be provided to me, at my request, and that I am encouraged to discuss all fees attendant to such care before services are rendered.

We accept cash, checks (with ID), VISA, Mastercard, American Express, Discover Card and Care Credit as forms of payment. A deposit will be required for all hospitalized pets and selected services.

I am aware that the practice of veterinary medicine is not an exact science and I understand that no warranty or guarantee with the provision of medical services is expressed or implied as to a cure or a specific result. I accept that my financial obligations remain regardless of the outcome.

All information I have provided here is true to the best of my knowledge. I have read and understand the Terms of Service.*

Attach pet medical records, if possible

Max. file size: 50 MB.

Client Service Agreement

Owner and Contact Information

Pet Information

Second Pet Information

Third Pet Information

Emergency Contact Information

More Information

Business Hours

(312) 643-2901