847-934-1535
arlingtonparkvethospital@gmail.com
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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.
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How were we selected to serve you?
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Previous Client
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(Google, Yelp, Etc.)
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Recommendation (by whom?)
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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.
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