New Client Registration

Date

Owner Name(s): *

Owner's Date of Birth: *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Home Phone: *

Work Phone: *

Ext:

Cell Phone: *

Email Address *

Patient #1 Name: *

Species: *

Breed: *

Sex: *

Spayed?: *

Neutered?: *

Color: *

Birthday:

Patient #2 Name:

Species:

Breed:

Sex:

Spayed?:

Neutered?:

Color:

Birthday:

Previous Veterinarian/Clinic: *

Phone: *

How Did You Hear About Us? If Internet, Please Specify Website: *

I understand and agree that if I need to cancel my appointment I need to provide 24 hours notice to Village Vet of Urbana or a charge will be applied to my account. If I do not show up to my scheduled appointment a charge will be applied to my account. Balances will need to be paid prior to scheduling any services or requesting any medication refills.

The Careteam at Village Vet of Urbana will request a deposit of $80 when scheduling an appointment for a new client and $50 deposit for current clients in an ongoing effort to reduce the number of now shows.

Village Vet of Urbana loves your pets and sometimes likes to post cute pictures, before/afters, and/or information about services or medical care he/she received at VVU on our FACEBOOK/INSTAGRAM pages. Please sign below if you give permission to Village Vet of Urbana to use your pet on our social media pages.

We do not accept checks We, our agents or assignees may call by telephone regarding your account. You agree that we, our agents or assignees may place such calls using an automatic dialing/announcing device. You agree that we, our agents or assignees, may make such calls to any telephone numbers you have provided including any mobile telephone or similar device. You agree that we, our agents or assignees may, for training purposes or to evaluate the quality of service, may listen to and record phone conversations you have with us and/or our agents or assignees. I, the undersigned, understand and agree to the fact that it is the policy of this animal hospital to receive payment in full at the time services are rendered, and that a deposit may be required upon admission to the hospital for treatment. In the event that it becomes necessary to turn an account over for outside collection, I agree to pay all costs of collection to include a 20% collection charge on the total balance owed.

Please Initial In The Box To Confirm *

*By electronically signing this document, I acknowledge that I have read, understood, and accepted all of the information provided. For the safety of all pets and people, please keep your pet restrained by leash or carrier at all times. Thank you!

Yes! Sign me up for the marketing email list.

Call Us! Button

Header Logo

Request an Appointment Button