NEW-CLIENT FORM

Thank you for giving us the opportunity to care for your cat. Please help us meet your needs better by taking a moment to complete this information sheet.

Contact Information

Enter only numbers and spaces
Enter only numbers and spaces
Enter only numbers and spaces
Enter only numbers and spaces
Enter only numbers and spaces
Enter only numbers and spaces

Referral Source


Microchip Identification


Social Media

We love social media! We would like your consent to share your pets’ image on our social media and website. Your full name and personal information will never be used.


Animal Medical History

Vaccinations

Give year last received. Type "unsure" if you don't know. Leave blank if not given.
Give year last received. Type "unsure" if you don't know. Leave blank if not given.
Give year last received. Type "unsure" if you don't know.
Which type was given?

Tests

(Feline distemper)

(Feline immunodeficiency virus)

Other History

How did you get your cat? (e.g. rescue shelter, natural birth, purchased from breeder, etc.)

You will have the opportunity to give the history of additional cats once this form is submitted.


Notifications

If you must cancel an appointment, we ask for 24 hours’ notice. If cancelling a surgical appointment, we ask for 48 hours’ notice.
A late cancellation or frequent cancellations may result in a fee being applied to your account.

Current vaccinations are required by Cat Hospital of Chicago before we may admit any cat for any reason. These measures are taken to protect the well-being of all animals and people within our hospital.

 


Consent to Treat

By selecting "YES" below, I hereby authorize the veterinarian to examine, prescribe for or treat the cats listed above. I assume responsibility for all charges incurred in the care of my cat(s). I understand that payment is always due in full at the time of service. I recognize that financial concerns should be discussed prior to exam and treatment.

For your convenience we accept Visa, Mastercard, Discover, cash and checks with proper identification. Please stop at the reception desk to review and pay for services.