217-543-2613 grahamvetclinic1@gmail.com

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New Clients

Name: Graham Veterinary Clinic
Address: 309 S Vine St, Arthur, IL, 61911, United States
Telephone: 217-543-2613
Price range: $

Welcome to Graham Veterinary Clinic!

Get Started

New Client Form

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following form. Please Note: All fields with * are required.

Name *

First

Last

Spouse's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone

Email *

County *

Place of Employment *

Best time to reach you? *

All Fees Are Due At The Time Services Are Rendered.

Please indicate choice of payment below: *

Cash/Check
Visa
MasterCard

How did you become aware of our clinic? *

Drive-by
Yellow Pages
Previous client
Other

If 'Other', please specify:

Personal Recommendation

Whom may we thank?

Pet Information

Name *

Breed *

Date of Birth *

Color *

Male or Female? *

Male
Female

Spayed/Neutered? *

Yes
No

Vaccination History

Applies to Dogs and Cats:

Rabies *

Fecal (Stool Sample) *

Applies to Dogs Only:

DHLP Parvo Corona (Virus Vaccination)

Bordetella

Heartworm Test

Heartworm Prevention

Yes
No

Applies to Cats Only:

Dist-Rhino Chlamydia

Leukemia Vaccine

FIV/FELV Test

Would you like to add a second pet? *

Yes
No

Second Pet

Name *

Breed *

Date of Birth *

Color *

Male or Female? *

Male
Female

Spayed/Neutered? *

Yes
No

Vaccination History

Applies to Dogs and Cats:

Rabies *

Fecal (Stool Sample) *

Applies to Dogs Only:

DHLP Parvo Corona (Virus Vaccination)

Bordetella

Heartworm Test

Heartworm Prevention

Yes
No

Applies to Cats Only:

Dist-Rhino Chlamydia

Leukemia Vaccine

FIV/FELV Test

Would you like to add a third pet? *

Yes
No

Third Pet

Name *

Breed *

Date of Birth *

Color *

Male or Female? *

Male
Female

Spayed/Neutered? *

Yes
No

Vaccination History

Applies to Dogs and Cats:

Rabies *

Fecal (Stool Sample) *

Applies to Dogs Only:

DHLP Parvo Corona (Virus Vaccination)

Bordetella

Heartworm Test

Heartworm Prevention

Yes
No

Applies to Cats Only:

Dist-Rhino Chlamydia

Leukemia Vaccine

FIV/FELV Test

Any previous serious illnesses or surgeries? *

Any allergies to vaccinations or medications? *

Is your pet on any special diets or medications? *

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 Graham Veterinary Clinic. Graham Veterinary Clinic will have sole discretion over what to do with the animal. *