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New Client Form

A deposit of $95.00 is required for all new client appointments and will be used toward the initial appointment. The deposit is non-refundable for “no shows” or if canceled without giving 24 hours’ notice.

We are glad to have the opportunity to care for your pet. Our mission is to provide compassionate care by our dedicated experts. To ensure exceptional service, please fill out this form completely. Please email your pet's medical records or fax to 1-800-549-3114.

Name*
First Last
Address*
Street Address City State ZIP Code
Do you give permission to RVAH to communicate with you by email?*
- Yes
- No
Do you give permission to RVAH to communicate with you by email and text message for appointment reminders?*
- Yes
- No
Primary Phone:*
- Home
- Mobile
- Work
Alternative Phone:
- Home
- Mobile
- Work
Email:*
Co-Owner Information
Co-Owner's Name
First Last
Co-Owner Phone:
- Home
- Mobile
- Work
Co-Owner Email:
Previous Veterinary Hospital
Do you have pet insurance?*
Name of Pet Insurance Company
Policy Number
Your Pet's Information
Pet's Name:*
Pet's Date of Birth:*
Date Format: MM slash DD slash YYYY
Breed:*
Color:*
Gender:*
Is your pet neutered/spayed?*
Is your pet microchipped?*
Pet's Microchip Number
Does your pet become uncomfortable or aggressive with new people or animals? If Yes, please describe so we can create the safest and most comfortable experience for you and your pet.
Has your pet experienced any vaccine reactions?*
Second Pet (if applicable)
2nd Pet's Name
2nd Pet's Date of Birth:
Date Format: MM slash DD slash YYYY
2nd Pet's Breed:
2nd Pet's Color:
2nd Pet's Gender:
Is your 2nd pet neutered/spayed?
Is your 2nd pet microchipped?
2nd Pet's Microchip Number
Does your pet become uncomfortable or aggressive with new people or animals? If Yes, please describe so we can create the safest and most comfortable experience for you and your pet.
Has your pet experienced any vaccine reactions?
Referral Information
How did you hear of Roscoe Village Animal Hospital?*
If it s a personal referral, please let us know their name! As a token of our appreciation, a $20.00 credit will be applied to their RVAH account for this referral.
If you have already scheduled an appointment, please enter the appointment date here. Thank you.
Additional Comments:
Veterinary Care Authorization:I hereby authorize the veterinarian to examine, prescribe for, or treat for the above-described pet. I assume responsibility for all charges incurred in the care of my pet(s). I also understand that all professional fees are due at the time services are rendered. I verify that all the information provided is accurate.*
- Yes
- No
Cancellation Policy: I understand that if it is necessary to cancel a schedu-led appointment, we require that clients call at least 48 hours in advance. A $100 cancellation fee will be charged for any surgical or dental procedure that is canceled without the 48-hour advanced notification. Our policies and procedures have been established to ensure the highest quality of care. No shows and late cancellations prevent others patients from receiving much-needed care or treatments.*
- Yes
- No
Social Media Authorization: I grant full permission to Roscoe Village Animal Hospital to use photos/videos of my pet(s) on social media sites and for marketing materials (printed or electronic). This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of my pet's photograph and/or name.*
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

Contact Us

3131 N. Clybourn Ave.
Chicago, Illinois 60618
Phone: (773) 549-3131
Fax: (800) 549-3114
info@roscoevillageanimalhospital.com

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Hospital Hours

Monday-Friday: 7am-7pm

Saturday: 8am-4pm

Sunday: 9am-3pm
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