Meadows Veterinary Clinic of East Peoria
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New Client Form
Thank you for choosing Meadows Veterinary Clinic! We are looking forward to meeting you and your pet!
Please complete the following form to help us make your first visit more efficient. Once you submit the completed form, we will contact you within 1 to 2 business days for scheduling. If you have a pet emergency or your pet is currently ill, please contact our office at 309-694-0505 for faster scheduling!
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Indicates required field
What kind of appointment do we need to schedule for your pet? (for example, would you like to schedule for vaccines? an illness? surgery?)
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Please choose one:
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I need to schedule an appointment for my pet. Please give me a call after receiving my information.
I have already scheduled my appointment, but I wanted to provide some additional information.
Personal Information
Pet Owner's Name
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First
Last
Spouse/Significant Other Name
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Home Street Address
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City / State / Zip Code
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Phone Number
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Alternate phone number
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Place of Employment
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Work Phone Number
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Email Address
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What is the best time and place to reach you?
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Please provide the Name and Relationship of any other persons that you want to allow to authorize care for your pet(s).
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Pet Information
Pet's Name
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This pet is a:
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Cat
Dog
This pet is a:
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Spayed Female
Intact Female (not spayed)
Neutered Male
Intact Male (not neutered)
Pet's Breed
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Pet's Color or Distinguishing marks
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Pet's birthday or approximate age
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Has your pet been seen previously by another veterinarian? If so, please provide the name of the previous clinic or doctor.
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Please select an option below:
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. I will bring my pet's medical records with me to my appointment
. Please call my previous clinic and have the records transfered for me
Does your pet have any fears or dislikes?
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Does your pet have any food sensitivities or require a prescription diet?
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Has your pet experienced any adverse reactions to medications or vaccines in the past?
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Does your pet currently take any medication?
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If you have additional pets, please provide their information below.
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Other Details
Preferred Method of Payment - Please check all that apply
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Cash
Check
Visa or Mastercard
Debit Card
We kindly ask that payment is made at time of service. Treatment plans with associated costs are available upon request. No charging is allowed, but if you need financial assistance, ask a staff member about our "90 Days Same As Cash" program through Personal Finance (pre-approval is needed to use this payment option).
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. I understand my payment options.
If you selected "Check" from the list above, please provide your Driver's License number
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I authorize Meadows Veterinary Clinic to take photos of my pet and use these photos for any lawful purpose including, for example: illustration, advertising, or Web content.
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Yes
No
I authorize Meadows Veterinary Clinic to release medical records for my pet(s) upon request (for example, if requested by grooming facility, kennel, daycare, emergency clinic, etc).
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Yes
No
How did you become aware of our clinic?
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Drove by
Yellow Pages or other advertisement
Website or Facebook page
Recommendation from a current client
If you were given a personal recommendation for our clinic whom may we thank?
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Submit