(815) 399-4808
| M, T, TH, F: 7:30am - 5:30pm | W: 8am - 5:30pm | S: 9am - 12pm | Sun: Closed
Online Pharmacy
Care Credit
Call for an Appointment
Home
About
Meet Our Team
Work With Us
Services
Our Services
Client Resources
New Client Form
Payment Information
Education
Links & Resources
Contact
(815) 399-4808
| M, T, TH, F: 7:30am - 5:30pm | W: 8am - 5:30pm | S: 9am - 12pm | Sun: Closed
Online Pharmacy
Care Credit
Call for an Appointment
Home
About
Meet Our Team
Work With Us
Services
Our Services
Client Resources
New Client Form
Payment Information
Education
Links & Resources
Contact
Call for an Appointment
New Client Form
Client and Contact
First and Last Name
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Cell Phone
*
Email
*
DOB
*
How did you become aware of this clinic?
Choose one
*
Hospital Sign
Internet
Another Client
Advertisement
Social Media
Other
If other, please specify
If another client, please specify who referred you
Emergency Contact Person
*
Home Phone
*
Cell Phone
*
Name of Previous Veterinarian
Phone of Previous Veterinarian
Pet Information
Pet 1
Pet 1 Name
*
Sex
*
Species
*
Canine
Feline
Exotic
Avian
Reptile
Breed
*
Color
*
DOB
*
Pet 2 (optional)
Pet 2 Name
Sex
Species
Canine
Feline
Exotic
Avian
Reptile
Breed
Color
DOB
Pet 3 (optional)
Pet 3 Name
Sex
Species
Canine
Feline
Exotic
Avian
Reptile
Breed
Color
DOB
Our Fee Policy
*
I understand that all fees are due at time of service. If you are in need of alternative payment arrangements please discuss that prior to completion of services.
Yes, I understand the fee policy.
Consent
*
I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I understand that all animals must be current on vaccinations and testing for boarding, grooming, daycare and hospital procedures. I assume all responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid for at the time of release and that a deposit may be required for surgical treatments or hospitalization.
Photo Release: I agree that Alpine Veterinary Hospital may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, or social media sites.
I have read the above statement and by submitting this form, I understand and agree to the conditions above.
Accept
Phone
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