ROSCOE VILLAGE ANIMAL HOSPITAL

"Where we treat our patients and clients the way we would want our pets and ourselves to be treated!"

 

  3131 N. Clybourn Avenue    Chicago, Illinois 60618    Telephone: (773) 549-3131    

Scott M. Rovner, DVM    Lindsay J. Seilheimer, DVM     Michele Gasper, DVM

Providing all your animal hospital needs in the Chicagoland area.

 

 

 

 

We're Currently Under Construction

 

 

If you're new to Roscoe Village Animal Hospital, you can register online. 

 

Simply fill out the form below, and press "SUBMIT"

when you have completed the information.

 

 

 

 

 

NEW PATIENT & CLIENT INFORMATION SHEET

 

Welcome to Roscoe Village Animal Hospital. So we may provide you with exceptional service, please share information about you and your pet(s). 

Our mission is to provide our clients with the very best loving, compassionate veterinary health and wellness care from before hello to beyond good-bye.

 

 

 

PATIENT INFORMATION

 

Pet’s name

 

Sex:  Male   Female          Neutered or spayed?  Yes  No

 

Species:  Dog   Cat    Other

 

Pet’s Date of Birth    Breed    Color

 

Reason for bringing pet in

 

Does your pet have any allergies, special medications, seizures, or health problems we should know about?  Yes  No

 

If yes, what?

 

What type of food does your pet eat?    Treats?

 

 

CLIENT INFORMATION

 

First name   Last name

 

Spouse first name   Spouse last name

 

Address    City    State    Zip

 

Home phone    Work phone   Ext   Cell

 

E-mail address   Employer

 

For check writing privileges, please provide your Driver’s License # Exp.

 

How did you become aware of  Roscoe Village Animal Hospital?

 

 Referred by friend    Whom may we thank? 

 

 Referred by Pet Store Whom may we thank?

 

 Drove by       Brochure           Previous Client of Higgins Animal Hospital     Website, www.roscoevillageanimalhospital.com

 Other: please specify    Bow Wow Bash    Chicago Canine Rescue Foundation   Yelp   Angies List

 

We appreciate payment when services are rendered.  For your convenience, we accept Cash, Check, MasterCard, Visa, Discover, American Express & Care Credit.

 

 

Date     You may FAX your pet's records to us at: (800) 549-3114

 

 

BY PRESSING "SUBMIT" YOU VERIFY THAT ALL INFORMATION IS CORRECT AS ENTERED ON THIS ONLINE FORM.