New Client Information Form Welcome to Burr Ridge Veterinary Clinic and thank you for giving us the opportunity to care for your pet! Please complete and submit our New Client Information Form before your appointment so we have all the information needed to contact you. Thank you!Download fillable PDF New Client Form hereOwner InformationOwner’s Name* First Last Primary Phone Number*Type of Phone* Cell Phone Work Phone Home Phone Secondary Phone NumberType of Phone Cell Phone Work Phone Home Phone Email Spouse/Other Name First Last Spouse/Other Cell Phone NumberSpouse/Other Work Phone NumberAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* DuPage Cook Will What is your preferred phone number for us to call you? Telephone (Cell) Telephone (Home) Telephone (Work) Children and Visitor NamesHow did you hear about us? Hinsdale Humane Soc. Google Search NextDoor Neighbors Magazine Event (Open House, Community Event) BRVC Client Trainer Another Clinic Name – so we may send a thank you* Name – so we may send a thank you* Name – so we may send a thank you* Please provide an emergency contact number which will only be used if we are unable to reach you while your pet is in our care:Name of Emergency Contact* First Last Phone number of emergency contact*I understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we take MasterCard, Visa, Discover, American Express, or Care Credit. There will be a $25.00 service charge for any check returned unpaid. To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines. The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice. Please note your contact information will only be shared with our vendors to notify you about appointments and service reminders, and to communicate important information about BRVC and/or your pet(s).* I understand the above statements On occasion we may take a photo of your pet for educational or social media use, please check here if you do NOT want photos of your pet(s) used Pet InformationPet's Name* Species* Dog Cat Other DOB* Sex* Breed* Color* Add a second pet?* Yes No Second Pet InformationPet's Name* Species* Dog Cat Other DOB* Sex* Breed* Color* Add a third pet?* Yes No Third Pet InformationPet's Name* Species* Dog Cat Other DOB* Sex* Breed* Color* Add a fourth pet?* Yes No Fourth Pet InformationPet's Name* Species* Dog Cat Other DOB* Sex* Breed* Color* Signature of Responsible Agent for Pet(s)Sign here*Date* MM slash DD slash YYYY Δ
