South Town Animal Hospital - South Elgin vet > New Client Form

New Client Form

Fill in information below and receive $15 off first visit
Name*
First Last
Address*
Street Address City State ZIP Code
Enter County name (ex: Kane, Cook ...)*
Best Contact Number (numeric only)*
Email*
May we use this email?*
- Yes
- No
Optional Co-Owner Name
First Last
Optional Relationship to Owner
Optional Co-Owner Phone
Pet(s) Information*
NAME BREED BDAY/AGE SEX (F or M) NEUTERED/SPAYED? Y/N COLOR CHIPPED? Y/N
Pet(s) Previous Vets (N if none)*
May we use your pet's photos on social media?*
- Yes
- No
Are you 65+ to qualify for our senior discount?*
- Yes
- No
What pet insurance do you have? (N for none)*
How did you hear about South Town Animal Hospital (select one)?*
- Family/Friend
- Business
- Anderson Animal Shelter
- Web Search
- Facebook
- Location
- Yellow Pages
- Drive By
- Other
If referred by a South Town client please enter their name.
Payment expected when services are rendered. By signing this Electronic Signature Consent Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I understand that my electronic signature is legally binding. By signing below, I accept the conditions of this agreement.
Type Signature Name*
First Last
Date (mm/dd/yyyy)*
MM slash DD slash YYYY
CAPTCHA
Once you complete the form you will be redirected to a 'Thank You Page'. However, if there are any errors you will be redirected back to your 'New Client Form' Entry to scroll through to correct the marked error(s) and to recheck the Captcha before submitting again.