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Call Us: 847-256-1131
 
Text Us: 847-256-1131
 
1419 Lake Ave Wilmette, IL
 
 
 

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New Client Registration Form
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.



Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s).  The required sections have a red * asterisk.

Owner's Name
Name*



First



Last


Address*



Street Address


Address Line 2


City


State / Province / Region


ZIP / Postal Code

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Country


Day-Time Phone*
Evening Phone
Mobile Phone
Email*



Enter Email



Confirm Email


Co-owner's Name & Contact #
Name



First



Last


Phone
How did you find out about our practice?
Clinic Location
Personal Referral
Internet Search / Website
Yellow Pages
Clinic Sign
Newspaper / Print Media
Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information
Pet's Name*
Species*
DogCatRabbitFerretBirdReptile
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Neutered MaleSpayed FemaleMaleFemaleUnknown
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)


Date Format: MM slash DD slash YYYY

What vaccines were given at this time
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet


 












Δ


Location:
 
1419 Lake Ave.

Wilmette, IL 60091
 
Contact:
 
Call Us: (847) 256-1131

Text Us: (847) 256-1131

Email: help@terryah.com
Hours:
 
M-F: 8:00am-5:30pm

Sat: 8:00am-1:00pm

Sun: Closed
 Get Directions
After-Hours Emergency:
In the event of a medical emergency outside of our business hours, we urge you to reach out to:
Blue Pearl: 847-564-5775
Vet Specialty: 847-459-7535
MedVet: 773-281-7110

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