New Clients | Higland Park Veterinary Clinic

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Home
Meet The Staff
Services
Resources
Reviews
Contact Us
Emergencies +

Home
Meet The Staff
Services
Resources
Reviews
Contact Us
Emergencies +

New Clients

Welcome new clients! Please fill out the following form:

Owner Name*
First Last
Owner Cell Phone Number*
Co- Owner Name
First Last
Co- Owner Cell Phone Number
Email
Address*
Street Address Address Line 2 City State ZIP Code
Pet Name*
Pet Birth Date
MM slash DD slash YYYY
Breed
Species*
Color
Sex*
- Male
- Female
Spay/ Neutered?*
- Yes
- No
Does your pet have a microchip?*
- Yes
- No
Currently on heartworm medicine*
- Yes
- No
History of Medical Conditions?*
Please list your pet's medical conditions
Additional Pet?
- Yes
- No
Pet Name
First Last
Pet Birth Date
MM slash DD slash YYYY
Breed
Species
Color
Sex
- Male
- Female
Spay/ Neutered?
- Yes
- No
Does your pet have a microchip?
- Yes
- No
Currently on heartworm medicine
- Yes
- No
History of Medical Conditions?
Please list your pet's medical conditions
Previous Clinic Name
Previous Clinic Phone
How Did You Hear About Us?
- Yelp
- Google
- Neighborhood
- Referral
I authorize Highland Park Veterinary Clinic to take pictures of my pet to post on social media (instagram, facebook, etc) or for educational purposes.
- Yes
- No
I agree to pay fees for services rendered at the time the pet is discharged from the clinic or the service is otherwise terminated. I also understand that if hospitalization is needed, then a deposit may be required.
- Yes
- No
I certify that I am 18 years old or older and the owner or agent of the animal.
- Agree
- Disagree
Email
This field is for validation purposes and should be left unchanged.

Highland Park Veterinary Clinic
176 Skokie Valley Road
Highland Park, IL 60035
Phone : 847-926-7444
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Hours of Operation: Mon/Tues - 8am to 5pm | Thurs 8am to 5pm | Fri 8am to 4pm | Sat 9am to 1pm | CLOSED Sun & Wed