Niles Animal Hospital & Bird Medical Center

Contact Us

7278 North Milwaukee
Niles, IL
60714

Ph: 847-647-9325
Fax: 847-647-8498
E: info@nilesanimalhospital.com

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
Salutation
Name*
First Last
Co-owner's Name & Contact #
Salutation
Name
First Last
Phone
Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Enter Email Confirm Email
How did you find out about our practice?
- Clinic Location
- Personal Referral
- Internet Search / Website
- Yellow Pages
- Clinic Sign
- Newspaper / Print Media
- Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
- Yes
- No
If Yes, please list the medication or supplement
What food does your pet eat?
does your pet have allergies or drug reactions?
- Yes
- No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
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.
I have read, understand and agree to the above
- Yes
- No
Date
Date Format: MM slash DD slash YYYY

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 4:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 4:00pm
Sunday	Closed

Contact Us

New Client Registration Form