Owner's First Name*

Owner's Last Name*

Co-Owner's First Name

Co-Owner's Last Name

Phone*

Email*

Pet Information

Patient's Name*

DOB / Age*

Breed*

If other, please specify*

Color*

If yes, please explain*

Previous Animal Hospital*

If referred, please share who so we can thank them!*

Photography Release

I grant to Companion Animal Hospital, it’s representatives and employees, the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree with Companion Animal Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content.

Signature*

Date*

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.

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

Signature*

Date*

ALL FEES ARE DUE AT THE TIME OF SERVICE

Signature*

Date*

Email

This field is for validation purposes and should be left unchanged.

New Client Form

Pet Information

Photography Release

Terms of Service

Get in touch

(847) 821-6189

Business Hours