Client Service Agreement

If you and your pet are planning to visit Companion Animal Hospital of Skokie for the first time, we look forward to seeing you! For a smoother transition into our practice, please take a few minutes to fill out the Client Service Agreement provided on this page. Just complete all of the boxes marked with ‘*’ and click the Submit button when you’re finished. If you have any questions about completing the form, you can reach us at (847) 966-3080.

New Client Form

Step 1 of 4

25%

Owner and Contact Information

Owner's Name(Required)

First

Last

Co-Owner's Name

First

Last

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

County(Required)

Primary Phone Number(Required)

Secondary Phone Number

Email(Required)

Pet Information

How many pets do you have?(Required)

Pet's Name(Required)

Date of Birth (Or Estimate)(Required)

MM slash DD slash YYYY

Species(Required)

Dog

Cat

Other

Please specify other species(Required)

Breed(Required)

Color(Required)

Gender(Required)

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?(Required)

Yes

If yes, please specify

Do you have your pet's medical records?(Required)

Yes

Are their medical records at another veterinary practice?

Yes

Name of pet's previous Animal Hospital

City/State of former practice

(if applicable)

May we call to request a copy of records before your visit with us?

Yes

Reason for your visit(Required)

Special requests or conditions

Pet #2

Pet's Name(Required)

Date of Birth (Or Estimate)(Required)

MM slash DD slash YYYY

Species(Required)

Dog

Cat

Other

Please specify other species(Required)

Breed(Required)

Color(Required)

Gender(Required)

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?(Required)

Yes

If yes, please specify

Do you have your pet's medical records?(Required)

Yes

Are their medical records at another veterinary practice?

Yes

Name of pet's previous Animal Hospital

City/State of former practice

(if applicable)

May we call to request a copy of records before your visit with us?

Yes

Reason for your visit(Required)

Special requests or conditions

Pet #3

Pet's Name(Required)

Date of Birth (Or Estimate)(Required)

MM slash DD slash YYYY

Species(Required)

Dog

Cat

Other

Please specify other species(Required)

Breed(Required)

Color(Required)

Gender(Required)

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?(Required)

Yes

If yes, please specify

Do you have your pet's medical records?(Required)

Yes

Are their medical records at another veterinary practice?

Yes

Name of pet's previous Animal Hospital

City/State of former practice

(if applicable)

May we call to request a copy of records before your visit with us?

Yes

Reason for your visit(Required)

Special requests or conditions

Pet #4

Pet's Name(Required)

Date of Birth (Or Estimate)(Required)

MM slash DD slash YYYY

Species(Required)

Dog

Cat

Other

Please specify other species(Required)

Breed(Required)

Color(Required)

Gender(Required)

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?(Required)

Yes

If yes, please specify

Do you have your pet's medical records?(Required)

Yes

Are their medical records at another veterinary practice?

Yes

Name of pet's previous Animal Hospital

City/State of former practice

(if applicable)

May we call to request a copy of records before your visit with us?

Yes

Reason for your visit(Required)

Special requests or conditions

Pet #5

Pet's Name(Required)

Date of Birth (Or Estimate)(Required)

MM slash DD slash YYYY

Species(Required)

Dog

Cat

Other

Please specify other species(Required)

Breed(Required)

Color(Required)

Gender(Required)

Male

Female

Male Neutered

Female Spayed

Does your pet have any drug or vaccine allergies?(Required)

Yes

If yes, please specify

Do you have your pet's medical records?(Required)

Yes

Are their medical records at another veterinary practice?

Yes

Name of pet's previous Animal Hospital

City/State of former practice

(if applicable)

May we call to request a copy of records before your visit with us?

Yes

Reason for your visit(Required)

Special requests or conditions

Emergency Contact(Required)

First

Last

Emergency Contact Phone Number(Required)

How did you hear about us?(Required)

Street Sign/Location

Google/Yahoo

Yelp

Facebook/Instagram

Public Event

Mailing

Shelter/Rescue (please provide name below)

Pet Store (please provide name below)

Boarding/Daycare/Grooming Facility (please provide name below)

Referred by family/friend (please provide their name below)

Referred by employee (please provide their name below)

Have been here before

Other

Who can we thank for the referral?

Photography Consent:

Agree

Disagree

I grant to Companion Animal Hospital, its representatives and employees, the right to take photographs of me, and/or my pets, or my designated agents for publish in print and/or to use electronically. I agree that Companion Animal Hospital, its representatives and employees may use such photographs for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

Terms of Service

I assume responsibility for all charges incurred in the care of this pet brought in by myself or another individual. PAYMENT IN FULL is required at the time services are rendered. We do not offer any form of billing. I understand that a treatment plan providing the details and costs for the anticipated veterinary services will be provided to me, at my request, and that I am encouraged to discuss all fees attendant to such care before services are rendered.

We accept cash, checks (with ID), VISA, Mastercard, American Express, Discover Card and Care Credit as forms of payment. A deposit will be required for all hospitalized pets and selected services.

I am aware that the practice of veterinary medicine is not an exact science and I understand that no warranty or guarantee with the provision of medical services is expressed or implied as to a cure or a specific result. I accept that my financial obligations remain regardless of the outcome.

All information I have provided here is true to the best of my knowledge. I have read and understand the Terms of Service(Required)

Owner signature or initials

Attach pet medical records, if possible

Max. file size: 50 MB.

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New Client Form

Owner and Contact Information

Pet Information

Pet #2

Pet #3

Pet #4

Pet #5

Terms of Service

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(847) 966-3080

(847) 966-3080

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