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 Spouse/Other Name First Last Address* Street Address County City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Children and Visitor NamesPlease provide us with at least one method to contact you about your pet’s health and related informationHome or Cell Phone Number*Please indicate which phone number you provided*CellHomeHome FaxEmail EmployerWork PhoneSpouse/Other EmployerSpouse/Other Work PhoneWhat is your preferred phone number for us to call you?*Telephone (Cell)Telephone (Home)Telephone (Work)How did you hear about us?Hinsdale Humane Soc.Google SearchNextDoorNeighbors MagazineDarien SportsplexEvent (Open House, Community Event)BRVC ClientTrainerAnother ClinicName – 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) usedPet InformationPet's Name*Species*DogCatOtherDOB*Sex*Breed*Color*Add a second pet?*YesNoSecond Pet InformationPet's Name*Species*DogCatOtherDOB*Sex*Breed*Color*Add a third pet?*YesNoThird Pet InformationPet's Name*Species*DogCatOtherDOB*Sex*Breed*Color*Add a fourth pet?*YesNoFourth Pet InformationPet's Name*Species*DogCatOtherDOB*Sex*Breed*Color*Signature of Responsible Agent for Pet(s)Sign here*Date* Date Format: MM slash DD slash YYYY
