New Client Form

We are glad to have the opportunity to care for your pet. Our mission is to provide compassionate care by our dedicated experts. To ensure exceptional service, please fill out this form completely. Please email your pet’s medical records to [email protected] or fax to 1-800-549-3114.

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Name*







Address*












Do you give permission to RVAH to communicate with you by email?*


Do you give permission to RVAH to communicate with you by email and text message for appointment reminders?*








Co-Owner Information

Co-Owner's Name










Your Pet's Information

Pet's Name:*


MM slash DD slash YYYY

Second Pet (if applicable)


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Referral Information

Veterinary Care Authorization:I hereby authorize the veterinarian to examine, prescribe for, or treat for the above-described pet. I assume responsibility for all charges incurred in the care of my pet(s). I also understand that all professional fees are due at the time services are rendered. I verify that all the information provided is accurate.*


Social Media Authorization: I grant full permission to Roscoe Village Animal Hospital to use photos/videos of my pet(s) on social media sites and for marketing materials (printed or electronic). This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of my pet's photograph and/or name.*








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(773) 549-3131

3131 N. Clybourn Ave.
Chicago, Illinois 60618

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