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 here

Owner Information

Owner’s First Name

Owner’s Last Name

Primary Phone Number

Type of Phone

Cell Phone

Work Phone

Home Phone

Spouse/Other First Name

Spouse/Other Last Name

Spouse/Other Cell Phone Number

Spouse/Other Work Phone Number

Address

Street Address

City

State/Province

ZIP Code

County

DuPage

Cook

Will

Other

What is your preferred phone number for us to call you?

Telephone (Cell)

Telephone (Home)

Telephone (Work)

Children and Visitor Names

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:

First Name of Emergency Contact

Last Name of Emergency Contact

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

Pet Information

Pet's Name

Species

Dog

Cat

Other

DOB

Sex

Breed

Color

Second Pet Information

Pet's Name

Species

Dog

Cat

Other

DOB

Sex

Breed

Color

Signature of Responsible Agent for Pet(s)

Sign here

Sign above

Date

New Client Information Form

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