Construction Notice: Outside our office is undergoing construction through September. Please access the parking lot from Springfield Ave. via Duncan Ave. If you have trouble finding us or expect to be late, call (217) 345-6481. Thank you for your patience and trust in our care for your furry loved ones.

New Client Form

Save time during your new client appointment. You can expedite your check-in by submitting this form prior to your first visit.

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New Client Check In

Please fill out this form as completely and accurately as possible.

New Client (CVVC)

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client's Birthday *

Daytime Phone

Layout

Phone Type *

Phone Number *

Evening Phone

Layout

Phone Type *

Phone Number *

Email *

Spouse/Co-Owner Information

Spouse/Co-Owner's Name

First

Last

Layout

Spouse/Co-Owner's Phone Type

Spouse/Co-Owner's Phone Number

Spouse/Co-Owner's Email

Pet's Name *

Age: Years, Months

Type of Pet *

Breed

Color

Sex *

Male
Female

Neutered/Spayed

Neutered
Spayed

Special requests or conditions?

Please list any additional pets here

Where was your pet previously seen for medical care? We will attempt to call ahead for your pet's medical/vaccine history. *

How did you hear about us? *

By indicating I agree and submitting this registration, I am responsible for any charges incurred by my pet while in the care of Country View Veterinary Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. I agree to pay all reasonable costs you incur to collect this debt. This includes, unless prohibited by law, all reasonable attorney's fees, filing fees, court costs, collection agency costs, service fees, and other related collection costs or contingencies. I understand that if any unpaid balance is turned over to a collection agency that a fee ranging from 30%-50% will be added to the total balance due. I hereby give you or any of your agents or assignees to whom you turn over any unpaid balance permission to obtain a report from a credit reporting agency and to take reasonable steps to verify my credit and or employment information. I give you or any of your agents or assignees to whom you turn over any unpaid balance to contact me regarding this transaction or any future transaction at any telephone numbers of which they are aware including cellular telephones by manually dialing, using an auto-dialer or pre-recorded message. *

I have read this statement and I Agree
I Disagree

Comment

New Client Form

New Client Check In

New Client (CVVC)

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Have a Question?

Visit any of our conveniently located clinics.
Your pet’s records are accessible at all three locations!

Country View Vet Clinic

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Village Pet Doctor

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Beaumont Animal Clinic

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