2801 W. White Oaks Dr.
Springfield, IL 62704
Thank you for giving White Oaks West Animal Hospital the opportunity to care for your pet. So that we may become better acquainted, please complete the following form.
Zipcode / City / State:
Your Place of Employment (Employer / Title):
Your Work Phone#:
List any children's names and ages:
Spouse Full Name:
Spouse Phone Number:
Spouse's Employment (Employer / Title):
Spouse Work Phone#:
How did you find out about our Hospital?
Species (Dog, Cat):
Sex (Select Spay/Neuter if applicable):
Date of Pet's Birth (or approximate age if known?):
Is your pet microchipped?:
Describe all foods, including the BRAND and the AMOUNT that you are feeding daily:
What heartworm and/or flea/tick preventative is your pet currently on and when was it last administered?:
How many hours of the day does your pet spend outdoors?:
What brand/type of treats do you offer? How ofter/how many per day?:
When did you acquire your pet?:
Where did you aquired your pet?:
Please list any other pets (Name and Species):
Is there any previous medical history (if so please give the name of the veterinarian so we can call for records)?
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:
Do you already have an appt scheduled? If so, what time/date?
If you have a medical concern that needs to be addressed, it is best to call to schedule an appointment.:
Briefly explain the reason for the appointment request:
In detail, are there any health concerns that you have currently?
Select Method of Payment
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.
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2801 W. White Oaks Dr. | Springfield, IL 62704
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