Owner’s Name*

First Last

Address*

Street Address City State ZIP Code

McHenry, Kane, Lake or Other

Cell Phone*

Home Phone*

Email*

Secondary Contact Name*

Secondary Contact Number:*

Relationship*

Please fill out for all your pets’

Pet's General Information*

Pet’s Name	Species	Breed	Description (Color)	Age/DOB	Sex	Spayed/Neutered	Microchip #

Previous Clinic*

Clinic Name	Clinic Phone #

Upload Records

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 256 MB.

We follow the state guidelines for the rabies vaccination. While presenting to our office you must have records or a rabies certificate showing proof of the vaccination. If the patient is not vaccinated, it is required for your pet to be seen. If the rabies vaccine is declined, your appointment will be canceled and any reservation fee will be forfeited.

(510 ILCS 5/8) (from Ch. 8, par. 358)

Sec. 8. Rabies inoculation.

Every owner of a dog or cat 4 months of age or older shall have their pet inoculated by a licensed veterinarian.

Initials*

How did you hear about our practice?

How did you hear about our practice?*

Individual
Lifestyles Publication
Valpak
Google
Facebook
Other

Please specify*

Someone we may thank?*

Do you qualify for our Senior Citizen Discount?*

Yes
No

(Age 55 or older)

D.O.B.*

Are you active or retired military?*

Yes
No

Must have ID present to mark your account for a discount

May we use your pet’s picture on our social media/hospital website?*

Yes
No

Consent*

I am the authorized owner of this pet.*

Consent*

I am over the age of 18 years old.*

Signature*

FINANCIAL POLICY

Thank you for choosing Huntley Animal Care for your pet’s health care needs. We are dedicated to providing the highest quality care to all of our patients. We have several payment options available to you, but please note that we are unable to extend credit or offer payment plans. If for any reason there is an outstanding balance on your account for services that were rendered, you will be sent to collections. There is a late fee of $25.00 if you are more than 10 minutes late to your appointment. Full payment is due at the time of service. In case of a major medical procedure, we may require a deposit. We do not accept checks or American Express. The following options are available at Huntley Animal Care:

Cash
Visa
Mastercard
Discover
Care Credit

Reservation Fee

I understand my reservation fee is non-refundable if I cancel or reschedule within 24 hours.

Signature*

Waiver of Responsibility and Liability for Prescriptions

Filled by Non-Veterinary Internet Pharmacies or Catalog Vendors

I hereby request a prescription for medication(s) for my pet so that I can purchase these products from an internet pharmacy or catalog vendor. I have been informed that the following risks exist when I obtain these products from such sources.

There is a possibility that the prescription drugs received from these vendors may be counterfeit, otherwise adulterated, and may not have been approved by the FDA; and pesticides may not have been approved by the EPA. This has occurred in the past and can recur.
As the provider of your pets’ care, our medical records keep track of all drugs dispensed by us to you. When you purchase your prescriptions elsewhere, our computer tracking system is not activated to print instructions for use or risks of adverse side effects or to send reminders for follow up exams and/or lab tests that may be needed to monitor results or adverse reactions.
You may not have the prescription drug(s) available soon enough to start your pets’ medication at the optional time to provide relief for his/her condition.
When prescription products are purchased elsewhere, our staff members are unavailable to teach you how to administer them.
The number of tablets or capsules, milligram size of the unit, volume and/or concentration of liquid, and the number of authorized refills may differ from that prescribed by the attending doctor.
Manufacturer rebates that would ordinarily be available for products purchased from our hospital generally will not be available.
The manufacturer’s warranties or guarantees for these products may not be valid. This means if your pets’ condition is not effectively treated with the product(s), manufacturers may not stand behind their products or product liability procedures. Additionally, the owners or and the doctors at this facility will be unable to assist you in claims against those manufacturers.
All state and federal prescribing laws apply, the same as if you purchased the medication here.
We will not be held liable for signing off on/calling in any outside pharmacy requests as we do not endorse any pharmacy other than our own.
It is your responsibility to determine if your online pharmacy is licensed in the state of Illinois.

I have read and understand the above, accept these risks, and am aware that this facility cannot accept any financial responsibility for paying or reimbursing me for any treatments required as a result of the use of products purchased from these sources. In the absence of negligence, I agree to hold this veterinary practice and affiliated doctors harmless for any deleterious effects or lack of effectiveness of drugs or vaccines purchased from any other source.

Signature of Owner or Authorized Agent*

Zero Tolerance Policy

We have zero tolerance for profanity, threats, or violence. If any of these behaviors are exhibited, all services from our clinic will be terminated immediately.

By initialing below, I acknowledge and agree to this policy.

Your Initials*

Name

This field is for validation purposes and should be left unchanged.

New Client/Patient Form

Please fill out for all your pets’

How did you hear about our practice?

FINANCIAL POLICY

Reservation Fee

Waiver of Responsibility and Liability for Prescriptions

Zero Tolerance Policy

Testimonials

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