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White Oaks West
Pet Chat, Veterinarian in Springfield IL White Oaks West Springfield IL White Oaks West Springfield IL

Appointment Questionnaire Form | Dogs/Cats

Owner contact information:



Pet's name:

Do you already have an appt scheduled?

If so, what time/date?

Briefly explain the reason for the appointment request:

Describe all foods, including the BRAND that you are feeding, and how much offered daily:

What brand/type of treats do you offer? How ofter/how many per day?:

How many hours of the day does your pet spend outdoors?:

What heartworm and/or flea/tick preventative is your pet currently on and when was it last administered?:

List any major medical issues/surgeries this pet has had throughout it's history?

List the names of any medications that your pet is currently taking and how much/often they are given:

Please list any other pets in the household (Name and Species):

I do further agree that should any payment become overdue more than five (5) days from the above agreed time of payment or payments, the entire balance shall be considered in default and become due and payable with interest finance charges from the date of default at the rate of one and one half percent (1-1/2%) per month, which is an annual percentage rate of eighteen percent (18%) applied to the previous balance without deducting current payments, and with the addition of any or all collection agency and/or attorney fees necessary to collect the full amount due to White Oaks West Animal Hospital without any relief whatever from Valuation or Appraisement Laws. I further agree that if my account becomes past due and is turned over for collection there will be a collection fee of 40% of the outstanding balance added for which I will be liable for.