Client Registration Form

Selecting an appointment date on this form does not confirm your appointment. Please provide your already scheduled appointment date that has been confirmed by our staff.
Confirmed Appointment Date*

MonthDayYear
Select the location at which you are seeking Treatment*

Chicago, ILMundelein, ILOrland Park, IL
Owner Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
State Guidelines require that the caregiver's date of birth be recorded when distributing controlled medications.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please enter a valid phone number: (###) ###-####
Primary Phone Type*
Please select your phone type
I grant permission to the hospital medical team to text reminders and updates to the mobile number provided here.*

YesNo
Email*
example@example.com
We will use your email to send appointment reminds, medical communications and a client survey.
Would you like to list a Co-Owner on your account?*

YesNo
Co-Owner's Name

First NameLast Name
Co-Owner's Phone Number
Please enter a valid phone number: (###) ###-####
Co-Owner's Email Address
example@example.com
Patient Information
How many pets would you like to register?*
Please select the number of pets to register
We take pictures of your pet for identification and as part of the medical record. These photos are not shared outside of the medical record.

Pet 1 Information
Pet 1: Name*
Pet 1: Age/Date of Birth*
Please enter the number of years (7 years), or enter the date of birth in the format: mm/dd/yyyy.
Pet 1: Species*

DogCatOther
Pet 1: Is it an indoor or an outdoor pet?

IndoorOutdoorBoth
Pet 1: Breed*
Pet 1: Sex*
Pet 1: Color/Markings*
Date of Most Recent Rabies Vaccination*

MonthDayYear
Date of Other Recent Vaccinations:
Vaccine Name:
Date:

MonthDayYear
Vaccine Name:
Date:

MonthDayYear
Vaccine Name:
Date:

MonthDayYear

Referring Veterinarian Information

Our medical team will communicate with the referring veterinarian indicated on the form to ensure continuity of care.
Primary Care Veterinarian Name
Name of the veterinarian who provides your pet's routine veterinary care.
Primary Care Veterinary Clinic*
Where do take your pet for routine care? If you do not know, or don't have one, please say "none".
Primary Care Clinic Phone
Please enter a valid phone number.

Owner Information