New Client Form

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Home
About
Fear Free
Blog
Contact
Client Forms
- New Client Form
- New Pet Form
Online Store

New Client Form

* Indicates required field

Today's Date *

Client Information

Name *

First

Last

Additional Name on Account *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

County *

Email *

Cell Phone Number *

Other Phone Number *

How do you prefer to receive vaccine reminders? *

Email Mail

How do you prefer to receive appointment reminders? *

Email Text Phone Call

How did you hear about us? *

Pet Information

Name *

Species *

Dog Cat

Breed *

Color *

Date of Birth (or approximate age) *

Gender *

Male Female

Spayed/Neutered *

Yes No

How old was your pet when you aquired them? *

Is your pet microchipped? *

Yes No Unsure

Brand of food being fed? *

Is heartworm prevention being given? *

Yes No

If yes, what type brand of heartworm prevention? *

Is flea prevention given? *

Yes No

If yes, what brand of flea prevention? *

Is your pet on medication *

Yes No

If yes, please list all medications your pet is receiving *

List prior illness or surgery *

May we put your pet's picture on West Lake Animal Hospital's Facebook page and/or website? *

Yes No

Please fill out the new pet form for each additional pet you would like to add to your account.

All payment is due at the time services are rendered. Please indicate your choice of payment below. *

Driver's License number (if paying by check) *

By checking the box below you are agreeing that should this account be turned over to a collection agency, you will be responsible for collection fees and attorney fees where applicable. *

I agree

Thank you for giving us the opportunity to serve you!
We look forward to seeing you in the clinic!

I agree to receiving marketing and promotional materials

Submit

We Would Love to Have You Visit Soon!

Hours
M- F 7:30am - 6:00pm

Telephone
217-529-4499
After Hours
217-698-0870

Physical Address
3220 Horizon Drive
Springfield IL 62703

Email
westlake125@comcast.net

New Client Form

Client Information

Pet Information

Please fill out the new pet form for each additional pet you would like to add to your account.

Thank you for giving us the opportunity to serve you! ​We look forward to seeing you in the clinic!

We Would Love to Have You Visit Soon!

Thank you for giving us the opportunity to serve you!
We look forward to seeing you in the clinic!