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New Client Form

 

PDF New Client Form (download and print)

Please fill out all applicable fields click "submit" to send your form data to Graham Veterinary Clinic. If you have an emergency or need to make an appointment, please phone (217) 543-2613.

Name:

Spouse's Name:

Address (street address, city, state zip):

County:

E-mail Address:

Home Phone:

Cell Phone:

Place of Employment:

Best Time to Reach You:

All Fees Are Due At The Time Services Are Rendered

Choice of Payment:

How did you become aware of our clinic?

If Personal Recommendation, Whom May We Thank?


Pet #1

Pet Name

Breed

Date of Birth

Color

Sex:
    

Spayed/Neutered:
    

Preventative Health History:

Any Previous Serious Illnesses or Surgeries?

Any Allergies to Vaccines or Medications?

Is Your Pet on Any Special Diets or Medications?


Pet #2

Pet Name

Breed

Date of Birth

Color

Sex:
    

Spayed/Neutered:
    

Preventative Health History:

Any Previous Serious Illnesses or Surgeries?

Any Allergies to Vaccines or Medications?

Is Your Pet on Any Special Diets or Medications?

 

Disclaimer (to be signed at your first visit):
I have provided information that is true and correct to the best of my knowledge. I hereby give Graham Veterinary Clinic permission to examine and treat my animal. Payment is due upon completion of visit. Graham Veterinary Clinic accepts cash, checks, and credit cards. If legal action is necessary to collect outstanding fees, I agree to be obligated for all collection fees incurred, including but not limited to filing fees, court cost & attorney or agent fees. Any animal left more than 10 days after the completion of services will be considered abandoned and will become property of the Graham Veterinary Clinic. Graham Veterinary Clinic will have sole discretion over what to do with the animal.