Burnham Park Animal Hospital

1025 S. State St
Chicago, IL 60605

(312)663-9200

burnhamparkvet.com

New Client Form

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form. Thank you!


New Client

Name (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Referral :
If referred, whom may we thank?

Are your pet's vaccines up to date? Check if yes.
Do you have your pet's medical records? Check if yes.
Medical records at another veterinary practice?
Yes
No


Name of former veterinary practice?

May we request a transfer of records?
Yes
No


Would you like us to call to schedule your appointment?
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here:

Consent Statement:
I understand that I am responsible for any charges incurred by my pet while in the care of the doctors at Burnham Park Animal Hospital, and that the charges are due and payable at the time of service. (Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Burnham Park Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.)
I have read this statement and I
Agree
Disagree



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