Okaw Veterinary Clinic

140 W. Sale
Tuscola, IL 61953

(217)253-3221

okawvetclinic.com

New Client Check In

 

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

Thank you for your cooperation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
Spouse/Other
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Home phone (required)
Phone TypePhone Number (required)
Cell phone
Phone TypePhone Number
Place of Employment

Work phone
Phone TypePhone Number
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


How did you hear about us?

Date of last vaccinations:

Do you have your pet's medical records?
Name of Former Veterinary Practice

Reasons or conditions that prompted your visit?

Has your pet had any previous surgeries or medical problems?

Is your pet on any medications? If so, list medications below.

How did you hear of us?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Okaw Veterinary Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 2%. Any balance that I leave unpaid will be forwarded to Okaw Veterinary Clinic's collection agency, and will incur a collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



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