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New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together. Please complete this from as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

  • Owner's Name

  • Co-owner's Name & Contact #

  • Address

  • Pet Information

  • Date Format: MM slash DD slash YYYY

  • All fees are due and payable on the day of treatment. A deposit for the first day of treatment is required on all hospitalized pets. Any outstanding bill will receive a monthly 1.5% finance charge and a $3.65 billing charge at time of billing. I understand I am fully responsible for all charges involved with my pet. In the case of nonpayment, I will be legally responsible for all charges involved with my pet and legally responsible to pay Niles Animal Hospital the total medical bill, all finance and billing charges, all attorney’s fees, and court costs involved with the case.

    As owner of this pet, I authorize treatment and payment in full including, if necessary, the above charges associated with the collection of the bill. I understand I may pay with CASH, CHECK, VISA, MASTERCARD, OR DISCOVERCARD.

  • Date Format: MM slash DD slash YYYY