New Clients: Receive $25 off your first visit!

Online Forms

New Client Form

Please fill out this form as completely and accurately as possible so we can
get to know you and your pet(s) before your visit.

Date

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell/Mobile

Email *

Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone

Spouse/Partner’s Name

Spouse/Partner’s Phone

How were we selected to serve you? *

Previous Client *

Internet *

(Google, Yelp, Etc.)

Phone Book *

Driving By *

Recommendation (by whom?) *

Patient Information

Name

Breed *

Date of Birth *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Vaccination History (Dog)

Canine Distemper
Rabies
Kennel Cough
Heartworm Test
Lyme Disease
Annual Wellness Exam
Wellness Blood Panel
Intestinal Parasite Exam

Vaccination History (Cat)

Feline Distemper
Rabies
Leukemia Test
Leukemia Vaccine
Annual Wellness Exam
Wellness Blood Panel
Intestinal Parasite Exam

Payment is due in full at the time that services are performed. If admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

Signature

Clear Signature

READY FOR A VISIT?

Call today to book an appointment. Please note our team books appointments 1-2 weeks in advance, and we are currently welcoming new clients!

Arlington Park Veterinary Hospital serves Arlington Heights, Palatine, Rolling Meadows, and surrounding communities.

BOOK APPOINTMENT

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Location

2105 Hicks Rd.
Rolling Meadows, IL 60008

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Contact

P: (847) 934-1535
F: 847-934-1932
E: arlingtonparkvethospital@gmail.com

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Hours

Mon–Fri: 8 a.m – 12 p.m & 2 p.m – 6 p.m
Wed: 8 a.m – 1 p.m & 2 p.m – 5 p.m
Sat: 8 a.m – 1 p.m
Doctors’ hours by appointment only

HAVE A QUESTION?

Get in touch! Complete the form below, and we will reach out to you shortly.

Name *

First

Last

Email *

Phone

How can we help you? *