630-208-7027 contact@animalcaregeneva.com

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New Client Form

Welcome to our clinic!

We’re excited to see you!

Before your first visit, be sure to complete your New Client Form. You can complete the form online by scrolling down or you can download and print by clicking the button below. If you need immediate assistance, please call us at 630-208-7027.

Please choose your Animal Care Clinic location:

Pingree
Algonquin
Geneva
South Elgin
Hoffman Estates (Barrington Square Animal Hospital)

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Work Phone

Employer

How did you hear about our practice? Whom may we thank?

Coupon
Drive By
Phonebook
Online
Other
Referral

Whom may we thank?

Name of Previous Veterinarian

Previous Veterinarian Phone Number

Pet Name *

Pet Species *

Dog
Cat
Other

If Other, please specify.

Pet Gender *

Male
Female

Spayed/Neutered? *

Yes
No

Pet Breed *

Pet Color *

Microchip Number *

Pet Birthday or Approximate Age *

Additional Pet?

Yes
No

Pet Name *

Pet Species *

Dog
Cat
Other

If Other, please specify.

Pet Gender *

Male
Female

Spayed/Neutered? *

Yes
No

Pet Breed *

Pet Color *

Microchip Number *

Pet Birthday or Approximate Age *

PAYMENT IN FULL IS DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. FOR YOUR CONVENIENCE, WE ACCEPT CASH, CHECKS AND MAJOR BANKCARDS (VISA, MASTERCARD, DISCOVER) AND CARE CREDIT AS FORMS OF PAYMENT. *

I have read and understand.

THE ABOVE LISTED CUSTOMER AGREES, BY SIGNING THIS AUTHORIZATION, TO PAY INTEREST AT THE RATE OF 1.50% PER MONTH, WHICH IS THE ANNUAL PERCENTAGE RATE OF 18% ON ANY PAST DUE ACCOUNT, AND TO PAY THE REASONABLE ATTORNEY’S FEES AND COURT COSTS OF ANIMAL CARE CLINIC OF FOX VALLEY, P.C., THAT ARE INCURRED IN THE COLLECTION OF ANY PAST DUE ACCOUNT. *

I have read and understand.

I HAVE READ/COMPLETED THIS FORM, UNDERSTAND IT AND AGREE TO ITS TERMS. *

I have read and understand.

Today's Date

Message

Contact Us

(630) 208-7027

contact@animalcaregeneva.com

1881 S Randall
Geneva, IL 60134

Pharmacy

(847) 423-0645

Hours

Mon - Fri: 7:00 am - 7:00 pm
Sat: 8:00 am - 3:00 pm
Sun: 10:00 am - 2:00 pm

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