Chicago Cat Clinic

New Patient Form 2020


Thank you for giving us the opportunity to care for your cat. Please help us meet your needs better by taking a moment to complete this information sheet.

November 9, 2020

At this time, we are asking all New Clients to place a non-refundable “New Patient Pre-Payment” of $75 to hold your appointment spot.  The Pre-Payment will apply to your charges on the day of your appointment.  The Pre-Payment will be forfeited if you are a “No-Show” for that appointment. 

CONTACT INFORMATION:

Primary Owner's Name

 

Patient Name

Secondary Owner's Name

 

Primary Address

 

Primary Home Phone                     Primary Work Phone                       Primary Cell Phone 

Primary Employer Information 

Secondary Employer Information 

Secondary Phone 

 

PATIENT INFORMATION:

Name

Reason For Visit?

Breed

Sex of Cat

Male Castrated (MC)

Female Spayed (FS)

Coat Color

Type of Food/Brand

Type of Litter/Brand

Microchip 

Declawed 

 

 

Date of last Vaccination:

Distemper

Rabies

Leukemia

How Did You Hear About Us?

Other:

 

 

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

Referred by an Individual:

Referred by an Another Veterinarian:

 

PAYMENT POLICY: We accept cash, Visa, Mastercard, Discover, American Express and Travelers checks. If you pay by check, please complete the following:

Driver's License Number/State   

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.

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

Leave this empty:

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Document name: New Patient Form 2020
lock iconUnique Document ID: 81cb7495d81dfbb2f97b8c05c89b0ac58c4f5e48
Timestamp Audit
February 8, 2017 6:27 pm CSTNew Patient Form 2020 Uploaded by Dr. John Nordwall - contactus@chicagocatclinic.com IP 107.185.241.32
July 23, 2020 3:33 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 107.185.241.32
July 27, 2020 3:18 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 107.185.241.32
July 27, 2020 3:19 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 107.185.241.32
July 27, 2020 3:25 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 107.185.241.32
July 27, 2020 3:56 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 72.223.112.74
July 27, 2020 4:03 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 72.223.112.74
July 27, 2020 4:03 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 72.223.112.74
July 27, 2020 4:05 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 72.223.112.74
July 27, 2020 4:06 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Dr. John Nordwall - contactus@chicagocatclinic.com as a CC'd Recipient Ip: 72.223.112.74
July 28, 2020 3:32 pm CST Document owner contactus@chicagocatclinic.com has handed over this document to haley@approveme.com 2020-07-28 15:32:44 - 72.223.112.74
July 28, 2020 3:32 pm CSTDr. Nordwall - contactus@chicagocatclinic.com added by Test Test - haley@approveme.com as a CC'd Recipient Ip: 72.223.112.74