Chicago Cat Clinic

New Client Form

Save time during your next appointment! Complete your required new client form online from any device at any time before your visit.

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Online Forms

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit If this is an emergency of is your pet needs urgent care, please call us at 773-631-5300 for a faster response.

Contact Information

Date

Primary Owner's Name *

First

Last

Primary Owner's Email *

Patient's Name *

Secondary Owner's Name *

First

Last

Primary Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Cell Phone *

Primary Home Phone

Primary Work Phone

Primary Employer Name *

Primary Employer Address *

Secondary Employer Name *

Secondary Employer Address *

Secondary Cell Phone *

Secondary Home Phone

Secondary Work Phone

Patient Information

Patient's Name *

Reason For Visit? *

Breed *

Coat Color *

Age/Date of Birth *

Sex *

Male
Male Castrated (MS)
Female
Female Spayed (FS)

Type of Food/Brand

Type of Litter/Brand

Does your pet have a microchip identification? *

Microchip #

Declawed

Date of last Vaccination:

Distemper

Leukemia

Rabies

What prior illnesses, surgery, or drug allergies should we know about?

Would you like to add a second pet? *

Patient's Name *

Reason For Visit? *

Breed *

Coat Color *

Age/Date of Birth *

Sex *

Male
Male Castrated (MS)
Female
Female Spayed (FS)

Type of Food/Brand

Type of Litter/Brand

Does your pet have a microchip identification? *

Microchip #

Declawed

Date of last Vaccination:

Distemper

Leukemia

Rabies

What prior illnesses, surgery, or drug allergies should we know about?

Would you like to add a third pet? *

Patient's Name *

Reason For Visit? *

Breed *

Coat Color *

Age/Date of Birth *

Sex *

Male
Male Castrated (MS)
Female
Female Spayed (FS)

Type of Food/Brand

Type of Litter/Brand

Does your pet have a microchip identification? *

Microchip #

Declawed

Date of last Vaccination:

Distemper

Leukemia

Rabies

What prior illnesses, surgery, or drug allergies should we know about?

Would you like to add a fourth pet? *

Patient's Name *

Reason For Visit? *

Breed *

Coat Color *

Age/Date of Birth *

Sex *

Male
Male Castrated (MS)
Female
Female Spayed (FS)

Type of Food/Brand

Type of Litter/Brand

Does your pet have a microchip identification? *

Microchip #

Declawed

Date of last Vaccination:

Distemper

Leukemia

Rabies

What prior illnesses, surgery, or drug allergies should we know about?

Would you like to add a fifth pet? *

Patient's Name *

Reason For Visit? *

Breed *

Coat Color *

Age/Date of Birth *

Sex *

Male
Male Castrated (MS)
Female
Female Spayed (FS)

Type of Food/Brand

Type of Litter/Brand

Does your pet have a microchip identification? *

Microchip #

Declawed

Date of last Vaccination:

Distemper

Leukemia

Rabies

What prior illnesses, surgery, or drug allergies should we know about?

How Did You Hear About Us?

Clinic Sign
White pages
Chicago Yellow
Neighborhood Yellow
Alternative phone book
Google
Yelp
Other

Other

If Referred By an Individual or Veterinarian? Please list their name below.

Referred by an Individual

Individual Name Referred by

Referred by an Another Veterinarian:

Veterinarian Name Referred by

I UNDERSTAND THAT ALL PROFESSIONAL AND HOSPITAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED AND MUST BE PAID IN FULL. I ACKNOWLEDGE THAT A DEPOSIT MAY BE REQUIRED FOR ANY PATIENT NEEDING TO BE HOSPITALIZED. We will gladly prepare a written estimate if you desire. Please ask the doctor. TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, HOSPITALIZED ANIMALS MUST BE CURRENT ON ALL VACCINES AND FREE OF INTERNAL AND EXTERNAL PARASITES. I AUTHORIZE THE DOCTOR TO PROVIDE VACCINES AND PARASITE CONTROL AS NEEDED FOR MY PET. *

I have read and accept the financial policy.

Please bring to your appointment any previous Veterinary records or upload an electronic copy below

Click or drag a file to this area to upload.

Comments

Message

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We’re Dedicated To Your Cats

We are proud to provide your cat with the highest quality veterinary services and offer a calm, quiet, canine-free environment. We proudly serve the cats of Edgebrook, Jefferson Park, Forest Glen, Niles, Lincolnwood, Edison Park, Morton Grove, Skokie, Harwood Heights, and surrounding communities. Easily request an appointment for your pet using our online system on PetDesk. Keep up with your pet’s health by downloading our app!

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