New Client Form

Welcome to Genoa Animal Hospital! Please fill out the following New Client Form prior to your first appointment. If you’re in need of immediate assistance, please contact us directly at (815) 784-6109.

We look forward to seeing you and your furry friends!

Name *

First

Last

Spouse's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Email *

Pet's Name *

Species *

Breed *

Color

Age/Date of Birth

Sex *

Male
Neutered Male
Female
Spayed Female

Previous Veterinarian

Where did you get your pet from?

How long ago?

Pet Insurance Company

Policy Number

How did you learn about our hospital?

Hospital Sign
Yellow Pages
Website
Referred By

All professional fees are due at the time services are rendered. We accept cash, checks, Mastercard, Visa, Discover, American Express, and Care Credit. Checks are processed electronically through Telecheck services. There is a $25 return check fee. In the event of a non-payment, Genoa Animal Hospital shall be entitled to the right of recovery for all collection expenses including interest charges, late fees, court costs, and reasonable attorney's fees incurred for the purpose of obtaining payment of the amount due. *

I have read and understand the above statement.

Digital Signature *

Date *

New Client Form

Helping People Help Their Pets.

Contact Info

Hours

Location

Get in touch!

Book an appointment with us!