New Clients

Thank you for choosing Plainfield Animal Hospital! Please either print our New Client Form, fill it out, and bring it with you to the hospital on the day of your first appointment, or simply fill out the online New Client Form below.

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Online New Client Information Form

Please fill in this form and click the submit button at the bottom of the page.

Owner's First Name   Owner's Last Name
Street Address
City/State   Zip Code
Home Phone   Work Phone
Cell Phone   Email
Pet's Name   Species
Breed   Date of Birth
Color   Sex
Spayed/Neutered?YesNo   Appt Date Time

Why did you choose our hospital?

    
Yellow Pages Good Reputation   Price Other pet(s) treated here
Internet Convenient Location   Referred If so, please type name below:

Why are you bringing in your pet?

  

When was your pet last vaccinated for:

   
Canine Distemper/Parvo/Corona   Canine Cough
Lyme Disease   Rabies
Feline Distemper   Feline Leukemia

Please check your method of payment for your visit:

Cash Check Visa Mastercard American Express Discover Care Credit

If you are not familiar with Care Credit, be sure to ask our receptionist for details.