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ACC-Algonquin-Blog

Home » New Client Form

New Client Form

We’re excited to see you!

Before your first visit, be sure to complete your New Client Form. If you need immediate assistance, please call us at 847-843-2226.

Client Information
How did you hear about our practice?
- Coupon
- Drive By
- Phonebook
- Online
- Other
- Referral
Name*

First

Last
Email*
Address*

Street Address

Address Line 2

City

State

ZIP Code
County
Driver's License #
Primary Phone*
Secondary Phone
Employer
Date of Appointment (if already scheduled)

MM slash DD slash YYYY
Name of Previous Veterinarian
Previous Veterinarian Phone Number
Pet Information
Pet Name*
Pet Species*
- Dog
- Cat
Pet Gender*
- Male
- Female
Spayed/Neutered?*
- Yes
- No
Pet Breed*
Pet Color*
Pet Birthday or Approximate Age
Additional Pet?
- Yes
- No
Please upload any relevant pet records here
Max. file size: 50 MB.
At Animal Care Clinic, we continually strive to provide the highest quality services through a responsive, professional staff with emphasis on individual attention and commitment to excellence in animal health care.
PAYMENT IN FULL IS DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. For your convenience, we accept cash, checks, major bankcards (Visa, Mastercard, Discover) and Care Credit as forms of payment.*
I have read and understand.
The above listed customer agrees, by signing this authorization, to pay interest at the rate of 1.50% per month, which is the annual percentage rate of 18% on any past due account, and to pay the reasonable attorney's fees and court costs of Animal Care Clinic that are incurred in the collection of any past due account.*
I have read and understand.
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Get in touch

847-683-9640

2401 W Route 20,
Pingree Grove, IL 60140

Make an appointment

Make an Appointment

Find Us

Business Hours

Monday

8:00am - 7:00pm

Tuesday

8:00am - 7:00pm

Wednesday

8:00am - 6:00pm

Thursday

8:00am - 6:00pm

Friday

8:00am - 6:00pm

Saturday

8:00am - 2:00pm

Sunday

Closed

Animal Care Clinic Pingree Grove

847-683-9640

2401 W Route 20,
Pingree Grove, IL 60140

Make an Appointment

Home
About
- Our Staff
- Hospital Tour
- Locations
- Blog
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Resources
Online Store
Contact

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