New Client Form

Name: Animal Care Clinic of Pingree Grove
Address: 2401 W Route 20, Pingree Grove, IL, 60140, United States
Telephone: 847-683-9640
Price range: $

Welcome to our clinic!

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 847-683-9640.

Client Information

How did you hear about our practice?

Coupon
Drive By
Phonebook
Online
Other
Referral

If Other, please elaborate

Whom may we thank?

Your Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County

Drivers License #

Primary Phone *

Secondary Phone

Employer

Date of Appointment (if already scheduled)

Name of Previous Veterinarian

Previous Veterinarian Phone Number

Pet Information

Pet Name *

Pet Species *

Dog
Cat
Other

If Other, please specify.

Pet Gender *

Male
Female

Spayed/Neutered? *

Pet Breed *

Pet Color *

Pet Birthday or Approximate Age

Additional Pet?

Pet Name *

Pet Species *

Dog
Cat
Other

If Other, please specify.

Pet Gender *

Male
Female

Spayed/Neutered? *

Pet Breed *

Pet Color *

Pet Birthday or Approximate Age

Please upload any relevant pet records here

Click or drag files to this area to upload. You can upload up to 5 files.

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. *