New Client Form
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1New Client Form
Thank you for choosing Pekin Animal Hospital. Please take a moment to familiarize us with you and your pet.
For your convenience you may print out this form and complete it before your petʼs first appointment with us.
Date:______________________
Owner Information
Last Name:_________________________________ First Name:____________________________ Middle Initial:____________
Spouseʼs Name:__________________________________________________________________________________________
Mailing Address:__________________________________________________________________________________________
City:_______________________________________________ State:_____________ Zip:_______________________________
Phone: (H)___________________________ (W)____________________________ (Cell)_____________________________
Email Address:_______________________________________________ Driverʼs Lic #:_________________________________
Employer:_______________________________________________________________________________________________
Previous Veterinary Hospital (if transferring):__________________________________________________________________
Pet #1 Information
Petʼs Name:______________________________________________________________________
☐ Feline
☐ Other______________________________________________________
Canine
Breed:_____________________________________________ ☐ Male
☐ Female
Color:______________________________________________ ☐ Neutered
☐ Spayed
Date of Birth:_________________________ Age:___________ Is your pet micro chipped? ☐ Yes
☐ No
Is your pet currently taking medication? ☐ Yes
☐ No
Name(s) of Medication:____________________________________________________________________________
Pet #2 Information
Petʼs Name:______________________________________________________________________
☐ Feline
☐ Other______________________________________________________
Canine
Breed:_____________________________________________ ☐ Male
☐ Female
Color:______________________________________________ ☐ Neutered
☐ Spayed
Date of Birth:_________________________ Age:___________ Is your pet micro chipped? ☐ Yes
☐ No
Is your pet currently taking medication? ☐ Yes
☐ No
Name(s) of Medication:____________________________________________________________________________
How Did You Hear About Us?
☐ Phone Book
☐ Internet/Website
☐ Previous Client
☐ Saw Sign
☐ Referral. Please print first and last name of person who referred you:______________________________________________
☐ Other:________________________________________________________________________________________________
Payment is expected at the time of service. How will you be paying for todayʼs services?
☐ VISA
☐ Mastercard
☐ Discover Card
☐ Cash
☐ Check
☐ Care Credit
Pekin Animal Hospital | Dr. Craig Peterson, Dr. Carl Johnson, & Dr. Nicole Chesher
221 Margaret St, | Pekin, IL 61554 | Phone: (309) 347-6674 | Fax: (309) 347-8946 | Email: pahwebservices@grics.net
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